MEDICARE: DIVINE GRACE CARE HOME LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1013891456
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE GRACE CARE HOME LLC

Provider Business Mailing Address
First Line	:	2620 CASCADE COVE DR
Second Line	:
City	:	LITTLE ELM
State	:	TX
Zip	:	75068-7602
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2620 CASCADE COVE DR
Second Line	:
City	:	LITTLE ELM
State	:	TX
Zip	:	75068-7602
Country	:	US
Telephone Number	:	469-463-4302
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GRACE ANIOKE
Credential	:
Telephone Number	:	469-463-4302

Provider Enumeration Date	:	07/31/2025
Last Update Date	:	07/31/2025

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