Healthcare Provider Details

I. General information

NPI: 1093042863
Provider Name (Legal Business Name): DIVINE INTERVENTION HEALTHCARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2009
Last Update Date: 11/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2158 45TH ST STE 303
HIGHLAND IN
46322-3742
US

IV. Provider business mailing address

2158 45TH ST STE 303
HIGHLAND IN
46322-3742
US

V. Phone/Fax

Practice location:
  • Phone: 708-821-5448
  • Fax: 708-566-5293
Mailing address:
  • Phone: 708-821-5448
  • Fax: 708-566-5293

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 Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MRS. SANDRENA ARMETTA HARRIS
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 708-821-5448