Provider Demographics
NPI:1215486071
Name:DIVINE HERITAGE, LLC
Entity type:Organization
Organization Name:DIVINE HERITAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CLARICE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:813-317-7991
Mailing Address - Street 1:8575 MONTRAVAIL CIR
Mailing Address - Street 2:#737
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-3035
Mailing Address - Country:US
Mailing Address - Phone:646-673-0044
Mailing Address - Fax:
Practice Address - Street 1:11911 PINE FOREST DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34654-1462
Practice Address - Country:US
Practice Address - Phone:813-317-7991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility