Healthcare Provider Details

I. General information

NPI: 1346831971
Provider Name (Legal Business Name): DIVINE C NFOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14111 RIVERBIRCH CT
LAUREL MD
20707-9484
US

IV. Provider business mailing address

14111 RIVERBIRCH CT
LAUREL MD
20707-9484
US

V. Phone/Fax

Practice location:
  • Phone: 702-418-9063
  • Fax:
Mailing address:
  • Phone: 702-418-9063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: