MEDICARE: DIVINE HOME HEALTH 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

General Provider Information

NPI Number	:	1063894798
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE HOME HEALTH CARE, INC

Provider Business Mailing Address
First Line	:	6107 MEMORIAL HWY
Second Line	:	SUITE B
City	:	TAMPA
State	:	FL
Zip	:	33615-4596
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3980 TAMPA RD
Second Line	:	SUITE 205H
City	:	OLDSMAR
State	:	FL
Zip	:	34677-3223
Country	:	US
Telephone Number	:	813-890-3400
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	GELYS GONGORA
Credential	:
Telephone Number	:	813-890-3400

Provider Enumeration Date	:	06/18/2015
Last Update Date	:	06/18/2015

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