Healthcare Provider Details

I. General information

NPI: 1336376458
Provider Name (Legal Business Name): DIVINE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PINE ST
MINDEN LA
71055-3213
US

IV. Provider business mailing address

201 PINE ST
MINDEN LA
71055-3213
US

V. Phone/Fax

Practice location:
  • Phone: 318-382-1366
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number15240
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number15240
License Number StateLA

VIII. Authorized Official

Name: KIMBERLY WESTON
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 318-382-1366