Provider Demographics
NPI:1063894798
Name:DIVINE HOME HEALTH CARE, INC
Entity type:Organization
Organization Name:DIVINE HOME HEALTH CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GELYS
Authorized Official - Middle Name:
Authorized Official - Last Name:GONGORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-890-3400
Mailing Address - Street 1:6107 MEMORIAL HWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-4596
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3980 TAMPA RD
Practice Address - Street 2:SUITE 205H
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-3223
Practice Address - Country:US
Practice Address - Phone:813-890-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health