MEDICARE: DIVINE PROVIDENCE VILLAGE

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility		PA

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

General Provider Information

NPI Number	:	1952428617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE PROVIDENCE VILLAGE

Provider Business Mailing Address
First Line	:	686 OLD MARPLE RD
Second Line	:
City	:	SPRINGFIELD
State	:	PA
Zip	:	19064-1239
Country	:	US
Telephone Number	:	610-328-7730
Fax Number	:	610-544-1710

Provider Business Practice Location Address
First Line	:	7115 BOYER ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19119-1810
Country	:	US
Telephone Number	:	610-543-5410
Fax Number	:	610-543-5397

Authorized Official
Title or Position	:	DIVISIONAL DIRECTOR
Name	:	MR. FRAN SWIACKI
Credential	:
Telephone Number	:	610-543-3380

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	11/13/2015

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Directions to “DIVINE PROVIDENCE VILLAGE ” Practice Location

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