MEDICARE: DIVINE PROVIDENCE VILLAGE

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1629433511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE PROVIDENCE VILLAGE

Provider Business Mailing Address
First Line	:	686 OLD MARPLE RD
Second Line	:
City	:	SPRINGFIELD
State	:	PA
Zip	:	19064-1239
Country	:	US
Telephone Number	:	610-328-7730
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 W ELKINTON AVE
Second Line	:
City	:	CHESTER
State	:	PA
Zip	:	19013-5027
Country	:	US
Telephone Number	:	610-543-3380
Fax Number	:

Authorized Official
Title or Position	:	HIPAA OFFICER
Name	:	DAWN ENGEL
Credential	:
Telephone Number	:	610-525-8800

Provider Enumeration Date	:	12/21/2015
Last Update Date	:	04/05/2024

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Directions to “DIVINE PROVIDENCE VILLAGE ” Practice Location

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