MEDICARE: DEVINE ADULT FAMILY CARE HOME

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	311ZA0620X	Adult Care Home Facility	6906841	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	N/A	OTHER		311ZA0620X

General Provider Information

NPI Number	:	1073969317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEVINE ADULT FAMILY CARE HOME

Provider Business Mailing Address
First Line	:	7913 SW 3RD ST
Second Line	:
City	:	NORTH LAUDERDALE
State	:	FLORIDA
Zip	:	33319
Country	:	UM
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7913 SW 3RD ST
Second Line	:
City	:	NORTH LAUDERDALE
State	:	FL
Zip	:	33068-1103
Country	:	US
Telephone Number	:	954-515-2104
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LOUNA DEVELIS
Credential	:
Telephone Number	:	954-515-2104

Provider Enumeration Date	:	05/05/2016
Last Update Date	:	05/05/2016

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