MEDICARE: DIVINITYCARES, INCORPORATION

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	302F00000X	Exclusive Provider Organization		LA

General Provider Information

NPI Number	:	1841280104
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINITYCARES, INCORPORATION

Provider Business Mailing Address
First Line	:	1202 COMMON ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-5254
Country	:	US
Telephone Number	:	337-990-0122
Fax Number	:	337-990-0124

Provider Business Practice Location Address
First Line	:	1202 COMMON ST
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70601-5254
Country	:	US
Telephone Number	:	337-990-0122
Fax Number	:	337-990-0124

Authorized Official
Title or Position	:	CEO
Name	:	MRS. EDIWNA HARMON BUSHNELL
Credential	:
Telephone Number	:	337-990-0122

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	07/21/2022

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