Provider Demographics
NPI:1538418561
Name:DEVINE HEALTHCARE LLC
Entity type:Organization
Organization Name:DEVINE HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADULT NURSE PRACTITIONER, OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TECONDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:ANP-BC
Authorized Official - Phone:314-496-1858
Mailing Address - Street 1:956 MOLLOY DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-3229
Mailing Address - Country:US
Mailing Address - Phone:314-496-1858
Mailing Address - Fax:
Practice Address - Street 1:956 MOLLOY DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3229
Practice Address - Country:US
Practice Address - Phone:314-496-1858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health