Provider Demographics
NPI:1366148421
Name:DIVINE GRACE RESIDENTIAL CARE LLC
Entity type:Organization
Organization Name:DIVINE GRACE RESIDENTIAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SABESTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ONYEPUNUKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-512-1675
Mailing Address - Street 1:930 E DEE ST
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-2777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4120 N 105TH LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-5843
Practice Address - Country:US
Practice Address - Phone:623-272-0428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness