1033359070 NPI number — DIVINE CHIROPRACTIC AND WELLNESS CENTER

Table of content: (NPI 1942262076)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033359070 NPI number — DIVINE CHIROPRACTIC AND WELLNESS CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVINE CHIROPRACTIC AND WELLNESS CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033359070
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
67 PARSONS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43215-3978
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-222-0019
Provider Business Mailing Address Fax Number:
614-222-0019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
629 S OHIO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43205-2743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-477-8140
Provider Business Practice Location Address Fax Number:
614-258-3811
Provider Enumeration Date:
03/04/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KORVAH-REED
Authorized Official First Name:
DEDDEH
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CHIROPRACTOR/OWNER
Authorized Official Telephone Number:
614-222-0019

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3769 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2805503 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".