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General NPI Number Information
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NPI Number | 1619784576
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Entity Type | Organization
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Legal Business Name | DIVINE CARE SERVICES
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Dates
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Enumeration Date | 12/14/2024
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Last Update Date | 12/14/2024
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Provider Practice Location Address
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Address Line | 6001 70TH AVE N
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City | BROOKLYN PARK
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State | MN
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Zip | 55429-1001
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Country | US
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Telephone | 712-501-0363
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Fax |
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Provider Business Mailing Address
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Address Line | 1120 52ND AVE NE
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City | FRIDLEY
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State | MN
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Zip | 55421-1876
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Country | US
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Telephone | 710-210-0363
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. T-MAX BLAYON BARLUE
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Credential | MD
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Telephone | 712-501-0363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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