Healthcare Provider Details

I. General information

NPI: 1770995219
Provider Name (Legal Business Name): DIVINITY HEALTHCARE SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S ELDER ST
NAMPA ID
83686-5212
US

IV. Provider business mailing address

620 S ELDER ST
NAMPA ID
83686-5212
US

V. Phone/Fax

Practice location:
  • Phone: 208-546-2051
  • Fax: 208-329-7001
Mailing address:
  • Phone: 208-546-2051
  • Fax: 208-329-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number StateID

VIII. Authorized Official

Name: MR. JEFFREY DONALD ROBERTS
Title or Position: OWNER
Credential: LPN, WCN
Phone: 208-546-2051