=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326150343
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINE HEALTHCARE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 12/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 856 UNIVERSITY AVE W
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-4807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-665-9795
-----------------------------------------------------
Fax | 651-665-9796
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 856 UNIVERSITY AVE W
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-4807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-665-9795
-----------------------------------------------------
Fax | 651-665-9796
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR/CEO/DON
-----------------------------------------------------
Name | ELIZABETH CHINWE OBI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-665-9795
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 205335700
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------