Provider Demographics
NPI:1992234082
Name:DIVINE CASE MANAGEMENT SERVICES, LLC
Entity type:Organization
Organization Name:DIVINE CASE MANAGEMENT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SELINA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-679-4861
Mailing Address - Street 1:PO BOX 81314
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-9314
Mailing Address - Country:US
Mailing Address - Phone:770-679-4861
Mailing Address - Fax:888-273-6606
Practice Address - Street 1:1237 SALEM GATE WAY SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1637
Practice Address - Country:US
Practice Address - Phone:770-679-4861
Practice Address - Fax:888-273-6606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA171M00000X
251K00000X, 251S00000X, 251T00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization