Provider Demographics
NPI:1396303384
Name:DIVINE HEALTHCARE SERVICES
Entity type:Organization
Organization Name:DIVINE HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:OBODIGBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-395-9501
Mailing Address - Street 1:60 EVERGREEN PL STE 501
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-2118
Mailing Address - Country:US
Mailing Address - Phone:973-395-9501
Mailing Address - Fax:973-395-9502
Practice Address - Street 1:60 EVERGREEN PL STE 501
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2118
Practice Address - Country:US
Practice Address - Phone:973-395-9501
Practice Address - Fax:973-395-9502
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVINE HEALTHCARE SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0254967Medicaid