Healthcare Provider Details

I. General information

NPI: 1376378521
Provider Name (Legal Business Name): DIVINE PERSONAL CARE AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 W GLEN OAKS LN STE 201
MEQUON WI
53092-3383
US

IV. Provider business mailing address

1009 W GLEN OAKS LN STE 201
MEQUON WI
53092-3383
US

V. Phone/Fax

Practice location:
  • Phone: 414-309-9700
  • Fax: 262-236-9536
Mailing address:
  • Phone: 414-309-9700
  • Fax: 262-236-9536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MELISSA ANN SLOAN
Title or Position: CEO/MANAGER
Credential:
Phone: 414-232-3962