MEDICARE: DIVINE NURSING CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	376J00000X	Homemaker
2	385H00000X	Respite Care
3	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1780333625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE NURSING CARE LLC

Provider Business Mailing Address
First Line	:	132 W LOGAN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-3620
Country	:	US
Telephone Number	:	267-289-4511
Fax Number	:

Provider Business Practice Location Address
First Line	:	132 W LOGAN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-3620
Country	:	US
Telephone Number	:	267-289-4511
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DENISE NICOLE EVERAGE
Credential	:
Telephone Number	:	267-982-6169

Provider Enumeration Date	:	03/19/2022
Last Update Date	:	03/19/2022

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