MEDICARE: DIVINE ANGELS SERVICES

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	253Z00000X	In Home Supportive Care Agency	230135	FL

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	000287900	OTHER	FL	DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED WAIVER SERVICES

General Provider Information

NPI Number	:	1790113306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE ANGELS SERVICES

Provider Business Mailing Address
First Line	:	10300 SW 72ND STREET
Second Line	:	SUITE 460-7
City	:	MIAMI
State	:	FL
Zip	:	33173-1828
Country	:	US
Telephone Number	:	786-316-5224
Fax Number	:	305-392-1828

Provider Business Practice Location Address
First Line	:	10300 SW 72ND STREET
Second Line	:	SUITE 460-7
City	:	MIAMI
State	:	FL
Zip	:	33173-1828
Country	:	US
Telephone Number	:	786-316-5224
Fax Number	:	305-275-1828

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DOMINICA CAMPOS
Credential	:
Telephone Number	:	786-316-5224

Provider Enumeration Date	:	10/16/2013
Last Update Date	:	07/28/2015

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Directions to “DIVINE ANGELS SERVICES ” Practice Location

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