Provider Demographics
NPI:1588321343
Name:DEVINE PROVIDENCE HOME LLC
Entity type:Organization
Organization Name:DEVINE PROVIDENCE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:TUEDJO
Authorized Official - Last Name:FEGAING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-375-3968
Mailing Address - Street 1:3025 BLUE JAY LN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-8705
Mailing Address - Country:US
Mailing Address - Phone:682-375-3968
Mailing Address - Fax:
Practice Address - Street 1:3025 BLUE JAY LN
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-8705
Practice Address - Country:US
Practice Address - Phone:682-375-3968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-29
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health