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General NPI Number Information
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NPI Number | 1780386730
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Entity Type | Organization
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Legal Business Name | DIVINE GRACE COUNTRY HOME LLC.
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Dates
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Enumeration Date | 03/21/2023
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Last Update Date | 03/21/2023
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Provider Practice Location Address
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Address Line | 7720 WRIGHT RD
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City | NILES
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State | MI
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Zip | 49120-9071
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Country | US
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Telephone | 269-449-4285
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 243
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City | BARODA
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State | MI
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Zip | 49101-0243
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Country | US
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Telephone | 269-449-4285
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Fax |
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Authorized Official
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Title or Position | MEMBER/OWNER
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Name | LISA MARIE OTT
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Credential |
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Telephone | 269-449-4285
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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