Healthcare Provider Details

I. General information

NPI: 1912292806
Provider Name (Legal Business Name): DIVINE INTERVENTION HEALTHCARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2011
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 LINCOLN MALL DR SUITE 502
MATTESON IL
60443-3811
US

IV. Provider business mailing address

4747 LINCOLN MALL DR SUITE 502
MATTESON IL
60443-3811
US

V. Phone/Fax

Practice location:
  • Phone: 708-248-7662
  • Fax: 708-248-7682
Mailing address:
  • Phone: 708-248-7662
  • Fax: 708-248-7682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. SANDRENA ARMETTA HARRIS
Title or Position: DIRECTOR OF NURSING
Credential: RN
Phone: 708-248-7662