Healthcare Provider Details

I. General information

NPI: 1982999090
Provider Name (Legal Business Name): DIVINE HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4238 W HAWTHORNE TRACE RD APT 104
BROWN DEER WI
53209-1026
US

IV. Provider business mailing address

4238 W HAWTHORNE TRACE RD APT 104
BROWN DEER WI
53209-1026
US

V. Phone/Fax

Practice location:
  • Phone: 414-975-0121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number126208-30
License Number StateWI

VIII. Authorized Official

Name: GOLD OMEREONYE
Title or Position: OWNER
Credential:
Phone: 414-975-0121