Healthcare Provider Details

I. General information

NPI: 1639663719
Provider Name (Legal Business Name): DIVINE HEALTHCARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12681 TREEYARD LN
SAINT LOUIS MO
63138-1440
US

IV. Provider business mailing address

12681 TREEYARD LN
SAINT LOUIS MO
63138-1440
US

V. Phone/Fax

Practice location:
  • Phone: 314-659-6254
  • Fax:
Mailing address:
  • Phone: 314-659-6254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number25320840
License Number StateMO

VIII. Authorized Official

Name: REBECCA BUFFORD
Title or Position: OWNER
Credential:
Phone: 314-532-2021