Provider Demographics
NPI:1457775744
Name:DIVINE RESIDENTIAL CARE AGENCY, LLC
Entity type:Organization
Organization Name:DIVINE RESIDENTIAL CARE AGENCY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAPHAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE BLAKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-281-2747
Mailing Address - Street 1:7061 FOXHALL DR
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-1269
Mailing Address - Country:US
Mailing Address - Phone:901-281-2747
Mailing Address - Fax:662-470-5771
Practice Address - Street 1:506 SPEEDWAY AVE
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MS
Practice Address - Zip Code:38967-1816
Practice Address - Country:US
Practice Address - Phone:901-281-2747
Practice Address - Fax:662-470-5771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility