MEDICARE: DIVINITY'S RESIDENTIAL SERVICE

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	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1497524250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINITY'S RESIDENTIAL SERVICE

Provider Business Mailing Address
First Line	:	2814 VIENNA VIEW CT SW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44706-5629
Country	:	US
Telephone Number	:	330-639-8258
Fax Number	:

Provider Business Practice Location Address
First Line	:	2814 VIENNA VIEW CT SW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44706-5629
Country	:	US
Telephone Number	:	330-639-8258
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TAMMI R NELSON
Credential	:
Telephone Number	:	330-639-8258

Provider Enumeration Date	:	12/21/2023
Last Update Date	:	12/21/2023

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Directions to “DIVINITY'S RESIDENTIAL SERVICE ” Practice Location

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