MEDICARE: ITS IN THE DIVINE 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578235016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ITS IN THE DIVINE LLC

Provider Business Mailing Address
First Line	:	18115 LITTLEFIELD ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-1466
Country	:	US
Telephone Number	:	313-205-4524
Fax Number	:

Provider Business Practice Location Address
First Line	:	607 SHELBY ST STE 700-1117
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48226-3268
Country	:	US
Telephone Number	:	313-766-2020
Fax Number	:	231-216-7580

Authorized Official
Title or Position	:	CEO
Name	:	MS. CRYSTAL DIXON
Credential	:
Telephone Number	:	313-205-4524

Provider Enumeration Date	:	10/04/2021
Last Update Date	:	10/04/2021

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Directions to “ITS IN THE DIVINE LLC ” Practice Location

Language	Start Address	Practice Location

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