Healthcare Provider Details

I. General information

NPI: 1508365032
Provider Name (Legal Business Name): DIVINE COMPANION CARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 MCDONALD AVE
RUSTON LA
71270-4627
US

IV. Provider business mailing address

616 MCDONALD AVE
RUSTON LA
71270-4627
US

V. Phone/Fax

Practice location:
  • Phone: 318-243-1743
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name: MS. MARKEDRA LYNNELL WHEATLEY
Title or Position: OWNER
Credential:
Phone: 318-243-1743