MEDICARE: DEVINE CONVALESCENT CARE CENTER INC

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	313M00000X	Nursing Facility/Intermediate Care Facility	112767	TX

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	HH027S	OTHER	TX	BLUE CROSS BLUE SHIELD TX

General Provider Information

NPI Number	:	1689660417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEVINE CONVALESCENT CARE CENTER INC

Provider Business Mailing Address
First Line	:	104 ENTERPRISE AVE
Second Line	:
City	:	DEVINE
State	:	TX
Zip	:	78016-1807
Country	:	US
Telephone Number	:	830-663-4451
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 ENTERPRISE AVE
Second Line	:
City	:	DEVINE
State	:	TX
Zip	:	78016-1807
Country	:	US
Telephone Number	:	830-663-4451
Fax Number	:

Authorized Official
Title or Position	:	INSURANCE/MEDICARE
Name	:	MR. JANICE PITA
Credential	:
Telephone Number	:	580-622-6300

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	08/28/2008

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