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General NPI Number Information
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NPI Number | 1982999090
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Entity Type | Organization
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Legal Business Name | DIVINE HEALTHCARE SERVICES
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Dates
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Enumeration Date | 06/16/2011
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Last Update Date | 06/16/2011
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Provider Practice Location Address
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Address Line | 4238 W HAWTHORNE TRACE RD APT 104
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City | BROWN DEER
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State | WI
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Zip | 53209-1026
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Country | US
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Telephone | 414-975-0121
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Fax |
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Provider Business Mailing Address
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Address Line | 4238 W HAWTHORNE TRACE RD APT 104
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City | BROWN DEER
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State | WI
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Zip | 53209-1026
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GOLD OMEREONYE
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Credential |
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Telephone | 414-975-0121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | 126208-30
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License Number State | WI
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