Healthcare Provider Details

I. General information

NPI: 1356811210
Provider Name (Legal Business Name): DIVINE HOME HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4028 VILLAGE TRACE BLVD
INDIANAPOLIS IN
46254-6218
US

IV. Provider business mailing address

PO BOX 532491
INDIANAPOLIS IN
46253-2491
US

V. Phone/Fax

Practice location:
  • Phone: 317-918-7545
  • Fax: 317-291-4351
Mailing address:
  • Phone: 317-918-7545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: EMMANUEL CHIKE OKEKE
Title or Position: PRESIDENT
Credential: DIRECTOR
Phone: 317-918-7545