Healthcare Provider Details

I. General information

NPI: 1275231037
Provider Name (Legal Business Name): DIVINE LIVING HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2023
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 GORDON AVE
MONONA WI
53716-1017
US

IV. Provider business mailing address

322 MILKY WAY
MADISON WI
53718-3026
US

V. Phone/Fax

Practice location:
  • Phone: 608-906-2037
  • Fax:
Mailing address:
  • Phone: 608-906-2037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: KAYI S MESSANVI
Title or Position: ADMINISTRATOR
Credential:
Phone: 608-906-2037