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General NPI Number Information
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NPI Number | 1932599610
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Entity Type | Organization
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Legal Business Name | DIVINE PRIVATE HOME CARE PROVIDER
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Dates
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Enumeration Date | 02/02/2015
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Last Update Date | 02/02/2015
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Provider Practice Location Address
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Address Line | 7317 DEXTER DR
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City | RIVERDALE
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State | GA
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Zip | 30296-1522
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Country | US
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Telephone | 678-517-5305
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Fax |
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Provider Business Mailing Address
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Address Line | 7317 DEXTER DR
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City | RIVERDALE
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State | GA
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Zip | 30296-1522
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Country | US
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Telephone | 678-517-5305
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MISS LATIFAT ABIMBOLA OKE
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Credential | BACHELOR IN NURSING
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Telephone | 678-517-5305
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 031-R-1124
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License Number State | GA
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