Provider Demographics
NPI:1962223131
Name:DIVINE HOME CARE OF MICHIGAN
Entity type:Organization
Organization Name:DIVINE HOME CARE OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-895-2171
Mailing Address - Street 1:25164 MAPLEBROOKE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-5282
Mailing Address - Country:US
Mailing Address - Phone:248-895-2171
Mailing Address - Fax:
Practice Address - Street 1:25164 MAPLEBROOKE DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-5282
Practice Address - Country:US
Practice Address - Phone:248-895-2171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care