MEDICARE: DIVINE ASSISTED CENTER

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	385HR2055X	Child Mental Illness Respite Care	120466	TX

General Provider Information

NPI Number	:	1558572156
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE ASSISTED CENTER

Provider Business Mailing Address
First Line	:	15502 EMPANADA DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77083-4112
Country	:	US
Telephone Number	:	832-788-0387
Fax Number	:

Provider Business Practice Location Address
First Line	:	15502 EMPANADA DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77083-4112
Country	:	US
Telephone Number	:	832-788-0387
Fax Number	:

Authorized Official
Title or Position	:	ADMINSTRATOR
Name	:	KATE IGBOWKE
Credential	:
Telephone Number	:	832-788-0387

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	11/05/2007

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Directions to “DIVINE ASSISTED CENTER ” Practice Location

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