Provider Demographics
NPI:1316449838
Name:DIVINE HEALING HOME CARE, LLC
Entity type:Organization
Organization Name:DIVINE HEALING HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:NYABOKE
Authorized Official - Last Name:MOGENI
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:763-566-1378
Mailing Address - Street 1:7240 BROOKLYN BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55429-1278
Mailing Address - Country:US
Mailing Address - Phone:763-566-1378
Mailing Address - Fax:763-566-1379
Practice Address - Street 1:7240 BROOKLYN BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN CENTER
Practice Address - State:MN
Practice Address - Zip Code:55429-1274
Practice Address - Country:US
Practice Address - Phone:763-566-1378
Practice Address - Fax:763-566-1379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN384593251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN384593OtherCOMPREHENSIVE HOME CARE LICENSE