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General NPI Number Information
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NPI Number | 1548586191
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Entity Type | Organization
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Legal Business Name | DIVINE CARE LLC
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Dates
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Enumeration Date | 04/07/2010
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Last Update Date | 01/05/2017
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Provider Practice Location Address
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Address Line | 16125 HYLAND AVE
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City | LAKEVILLE
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State | MN
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Zip | 55044-8883
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Country | US
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Telephone | 612-423-9765
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Fax | 952-236-9202
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Provider Business Mailing Address
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Address Line | 16125 HYLAND AVE
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City | LAKEVILLE
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State | MN
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Zip | 55044-8883
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Country | US
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Telephone | 612-423-9765
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Fax | 952-236-9202
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Authorized Official
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Title or Position | OWNER
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Name | MRS. FENTEZIA ZEWDIE
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Credential | RN
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Telephone | 612-423-9765
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number | 376844
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 376844
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License Number State | MN
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