MEDICARE: DIVINE HEALING HOME CARE, 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	251E00000X	Home Health Agency	384593	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	384593	OTHER	MN	COMPREHENSIVE HOME CARE LICENSE

General Provider Information

NPI Number	:	1316449838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE HEALING HOME CARE, LLC

Provider Business Mailing Address
First Line	:	7240 BROOKLYN BLVD STE 230
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55429-1278
Country	:	US
Telephone Number	:	763-566-1378
Fax Number	:	763-566-1379

Provider Business Practice Location Address
First Line	:	7240 BROOKLYN BLVD
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55429-1274
Country	:	US
Telephone Number	:	763-566-1378
Fax Number	:	763-566-1379

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. JOYCE NYABOKE MOGENI
Credential	:	RN
Telephone Number	:	763-566-1378

Provider Enumeration Date	:	02/28/2018
Last Update Date	:	12/16/2024

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