Healthcare Provider Details

I. General information

NPI: 1992234082
Provider Name (Legal Business Name): DIVINE CASE MANAGEMENT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 06/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1237 SALEM GATE WAY SE
CONYERS GA
30013-1637
US

IV. Provider business mailing address

PO BOX 81314
CONYERS GA
30013-9314
US

V. Phone/Fax

Practice location:
  • Phone: 770-679-4861
  • Fax: 888-273-6606
Mailing address:
  • Phone: 770-679-4861
  • Fax: 888-273-6606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. SELINA YVETTE ELLIS
Title or Position: OWNER
Credential:
Phone: 770-679-4861