Healthcare Provider Details

I. General information

NPI: 1023649209
Provider Name (Legal Business Name): DIVINE INTERVENTION HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 10/10/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 WOW RD
RANDLEMAN NC
27317-7951
US

IV. Provider business mailing address

2155 WOW RD
RANDLEMAN NC
27317-7951
US

V. Phone/Fax

Practice location:
  • Phone: 336-267-4517
  • Fax:
Mailing address:
  • Phone: 336-653-7916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: TRALVIS SHAW
Title or Position: CEO
Credential:
Phone: 336-267-4517