Healthcare Provider Details

I. General information

NPI: 1235892159
Provider Name (Legal Business Name): DIVINE PERSONAL CARE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2021
Last Update Date: 10/18/2021
Certification Date: 10/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8330 N TEUTONIA AVE STE 200
BROWN DEER WI
53209-1550
US

IV. Provider business mailing address

8330 N TEUTONIA AVE STE 200
BROWN DEER WI
53209-1550
US

V. Phone/Fax

Practice location:
  • Phone: 414-236-5608
  • Fax: 414-236-5632
Mailing address:
  • Phone: 414-236-5608
  • Fax: 414-236-5632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name: MELISSA A SLOAN
Title or Position: OWNER
Credential:
Phone: 414-232-3962