=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477653202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINITY HEALTHCARE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2006
-----------------------------------------------------
Last Update Date | 07/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3213 IH 30 STE. 205
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-2606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-929-7373
-----------------------------------------------------
Fax | 972-613-0950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3213 IH 30 STE. 205
-----------------------------------------------------
City | MESQUITE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75150-2606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-929-7373
-----------------------------------------------------
Fax | 972-613-0950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | PATRICK KALU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-929-7373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 009739
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 011556
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------