Healthcare Provider Details

I. General information

NPI: 1114622099
Provider Name (Legal Business Name): DIVINE GUARDIAN HEALTH ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2023
Last Update Date: 03/29/2026
Certification Date: 03/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 KILMER RD # 1328
EDISON NJ
08817-2432
US

IV. Provider business mailing address

6 KILMER RD # 1328
EDISON NJ
08817-2432
US

V. Phone/Fax

Practice location:
  • Phone: 973-847-3006
  • Fax:
Mailing address:
  • Phone: 973-847-3006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: JODIAN WALTERS
Title or Position: CEO
Credential:
Phone: 973-847-3006