MEDICARE: DIVINE HERITAGE, 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1215486071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE HERITAGE, LLC

Provider Business Mailing Address
First Line	:	8575 MONTRAVAIL CIR
Second Line	:	#737
City	:	TEMPLE TERRACE
State	:	FL
Zip	:	33637-3035
Country	:	US
Telephone Number	:	646-673-0044
Fax Number	:

Provider Business Practice Location Address
First Line	:	11911 PINE FOREST DR
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34654-1462
Country	:	US
Telephone Number	:	813-317-7991
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. CLARICE THOMAS ROBERTS
Credential	:	RN
Telephone Number	:	813-317-7991

Provider Enumeration Date	:	09/22/2016
Last Update Date	:	09/22/2016

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