=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013441658
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINE CONNECTION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2017
-----------------------------------------------------
Last Update Date | 04/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 442 HIGHWAY 1 S
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38701-4901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-219-8409
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 213 STONE ST
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38703-3451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-219-8409
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR/MANAGER
-----------------------------------------------------
Name | LAQUANDA WATSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-219-8409
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number | 2002
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------