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General NPI Number Information
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NPI Number | 1770995219
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Entity Type | Organization
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Legal Business Name | DIVINITY HEALTHCARE SERVICES PLLC
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Dates
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Enumeration Date | 06/02/2014
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Last Update Date | 05/08/2019
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Provider Practice Location Address
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Address Line | 620 S ELDER ST
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City | NAMPA
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State | ID
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Zip | 83686-5212
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Country | US
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Telephone | 208-546-2051
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Fax | 208-329-7001
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Provider Business Mailing Address
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Address Line | 620 S ELDER ST
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City | NAMPA
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State | ID
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Zip | 83686-5212
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Country | US
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Telephone | 208-546-2051
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Fax | 208-329-7001
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Authorized Official
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Title or Position | OWNER
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Name | MR. JEFFREY DONALD ROBERTS
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Credential | LPN, WCN
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Telephone | 208-546-2051
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State | ID
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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 |
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License Number State |
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