Provider Demographics
NPI:1619784576
Name:DIVINE CARE SERVICES
Entity type:Organization
Organization Name:DIVINE CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:T-MAX
Authorized Official - Middle Name:BLAYON
Authorized Official - Last Name:BARLUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:712-501-0363
Mailing Address - Street 1:1120 52ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55421-1876
Mailing Address - Country:US
Mailing Address - Phone:710-210-0363
Mailing Address - Fax:
Practice Address - Street 1:6001 70TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55429-1001
Practice Address - Country:US
Practice Address - Phone:712-501-0363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-14
Last Update Date:2024-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities