MEDICARE: DIVINITY HOME HEALTH 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

General Provider Information

NPI Number	:	1497887327
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINITY HOME HEALTH CARE LLC

Provider Business Mailing Address
First Line	:	30685 BARRINGTON ST
Second Line	:	SUITE 125
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-5111
Country	:	US
Telephone Number	:	313-690-7456
Fax Number	:	248-583-4233

Provider Business Practice Location Address
First Line	:	30685 BARRINGTON ST
Second Line	:	SUITE 125
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-5111
Country	:	US
Telephone Number	:	248-583-2733
Fax Number	:	248-583-4233

Authorized Official
Title or Position	:	OWNER
Name	:	MS. WILMA JEAN HARRIS
Credential	:	RN, MSN
Telephone Number	:	313-690-7456

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	07/08/2010

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