Healthcare Provider Details

I. General information

NPI: 1861712408
Provider Name (Legal Business Name): DIVINE HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2010
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 NASHVILLE HWY. STE. 10 SUITE 210
COLUMBIA TN
38401
US

IV. Provider business mailing address

PO BOX 1111 807 NASHVILLE HWY STE 10 STE 10
COLUMBIA TN
38401
US

V. Phone/Fax

Practice location:
  • Phone: 931-840-4119
  • Fax: 931-840-4121
Mailing address:
  • Phone: 931-840-4119
  • Fax: 931-840-4121

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: MR. WILLIE D ESMOND
Title or Position: OWNER
Credential:
Phone: 931-840-4119