MEDICARE: DIVINE HEART LLC

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	3104A0630X	Assisted Living Facility (Behavioral Disturbances)
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1902567084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE HEART LLC

Provider Business Mailing Address
First Line	:	21903 S 187TH WAY
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-6463
Country	:	US
Telephone Number	:	652-020-8197
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 W SOUTHERN AVE STE 3
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-4627
Country	:	US
Telephone Number	:	520-208-1970
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	FORSTER OKOLI
Credential	:
Telephone Number	:	520-208-1970

Provider Enumeration Date	:	01/01/2022
Last Update Date	:	03/14/2023

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Directions to “DIVINE HEART LLC ” Practice Location

Language	Start Address	Practice Location

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