MEDICARE: DIVINE BOYD ENTERPRISE 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	311Z00000X	Custodial Care Facility

General Provider Information

NPI Number	:	1427472133
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE BOYD ENTERPRISE LLC

Provider Business Mailing Address
First Line	:	117 CRYSTAL LAKE DR
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-3799
Country	:	US
Telephone Number	:	253-459-0863
Fax Number	:

Provider Business Practice Location Address
First Line	:	117 CRYSTAL LAKE DR
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-3799
Country	:	US
Telephone Number	:	253-459-0863
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	JOY BOYD
Credential	:
Telephone Number	:	253-459-0863

Provider Enumeration Date	:	02/17/2014
Last Update Date	:	02/17/2014

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Directions to “DIVINE BOYD ENTERPRISE LLC ” Practice Location

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