Organization
DIVINE HOUSE, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DEBRA JOANNE SHRIVER (OWNER)
(320) 231-2738
Entity
Organization
Contact information
Practice address
328 5TH ST SW, WILLMAR, MN 56201-3200
(320) 231-2738
(320) 231-3666
Mailing address
328 5TH ST SW, WILLMAR, MN 56201-3200
(320) 231-2738
(320) 231-3666
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
344820700
MN
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
754316600
MN
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
800666
MN
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
97395
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
030701087
PRIME WEST
MN
01
—
202D2DI
BCBS ID
MN
05
—
344820700
—
MN
01
—
754316600
PCA NUMBER
MN
Enumeration date
11/01/2006
Last updated
09/28/2016
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