=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396963534
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINE INTERVENTION MEDICAL STAFFING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21346 MAPLE HARVEST LN
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77338-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-202-7244
-----------------------------------------------------
Fax | 713-734-4364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21346 MAPLE HARVEST LN
-----------------------------------------------------
City | HUMBLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77338-2039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-202-7244
-----------------------------------------------------
Fax | 713-734-4364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT ADMINISTRATOR
-----------------------------------------------------
Name | CLEON L. SOLOMON III
-----------------------------------------------------
Credential | LVN
-----------------------------------------------------
Telephone | 832-202-7244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------