Provider Demographics
NPI:1124731443
Name:DIVINE AND COMPASSIONATE CARE LLC
Entity type:Organization
Organization Name:DIVINE AND COMPASSIONATE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OCTAVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:772-801-7771
Mailing Address - Street 1:919 S 25TH ST APT 2-102
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-4602
Mailing Address - Country:US
Mailing Address - Phone:772-801-7771
Mailing Address - Fax:
Practice Address - Street 1:919 S 25TH ST APT 2-102
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-4602
Practice Address - Country:US
Practice Address - Phone:772-801-7771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care