Organization
DIVINE HEALTHCARE SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GOLD OMEREONYE (OWNER)
(414) 975-0121
Entity
Organization
Contact information
Practice address
4238 W HAWTHORNE TRACE RD APT 104, BROWN DEER, WI 53209-1026
(414) 975-0121
Mailing address
4238 W HAWTHORNE TRACE RD APT 104, BROWN DEER, WI 53209-1026
Taxonomy
Speciality
Code
Description
License number
State
313M00000X
Nursing Facility/Intermediate Care Facility
Primary
126208-30
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
271904077
IRS
TX
Enumeration date
06/16/2011
Last updated
06/16/2011
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