Provider Demographics
NPI:1932861614
Name:DIVINE CARE HEALTH AND WELLNESS LLC
Entity type:Organization
Organization Name:DIVINE CARE HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC MENTAL HEALTH NURSE PRA
Authorized Official - Prefix:
Authorized Official - First Name:ELSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADIBE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:857-574-4497
Mailing Address - Street 1:500 WESTGATE DR # 1016
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1855
Mailing Address - Country:US
Mailing Address - Phone:857-574-4497
Mailing Address - Fax:
Practice Address - Street 1:500 WESTGATE DR # 1016
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1855
Practice Address - Country:US
Practice Address - Phone:857-574-4497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-09
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health