MEDICARE: DIVINE HEARTS HOME CARE INC

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	251E00000X	Home Health Agency	HC3518	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063551547
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE HEARTS HOME CARE INC

Provider Business Mailing Address
First Line	:	846 COUNTRY CLUB RD
Second Line	:
City	:	ROCKY MOUNT
State	:	NC
Zip	:	27804-1706
Country	:	US
Telephone Number	:	252-977-3711
Fax Number	:	252-977-3211

Provider Business Practice Location Address
First Line	:	846 COUNTRY CLUB RD
Second Line	:
City	:	ROCKY MOUNT
State	:	NC
Zip	:	27804-1706
Country	:	US
Telephone Number	:	252-977-3711
Fax Number	:	252-977-3211

Authorized Official
Title or Position	:	OWNER
Name	:	SHENITA DICKENS BETHEA
Credential	:
Telephone Number	:	252-977-3711

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	03/17/2008

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1962524736 — DIVINE HEARTS HOME CARE
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