Provider Demographics
NPI:1871107680
Name:DIVINE GRACE HOME CARE
Entity type:Organization
Organization Name:DIVINE GRACE HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANBENA
Authorized Official - Middle Name:
Authorized Official - Last Name:EMETO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-370-0860
Mailing Address - Street 1:5633 QUITMAN TRL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-6475
Mailing Address - Country:US
Mailing Address - Phone:919-370-0860
Mailing Address - Fax:
Practice Address - Street 1:5633 QUITMAN TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-6475
Practice Address - Country:US
Practice Address - Phone:919-370-0860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC200433Medicaid