1427426378 NPI number — DIVINE MEDICAL EQUIPMENT SUPPLY COMPANY

Table of content: VALERIE JEANNE BROOKE MD (NPI 1841599305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427426378 NPI number — DIVINE MEDICAL EQUIPMENT SUPPLY COMPANY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVINE MEDICAL EQUIPMENT SUPPLY COMPANY
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:
DIVINE HOME CARE SERVICES
Provider Other Organization Name Type Code:
3
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:
1427426378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15475 S PARK AVE STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH HOLLAND
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60473-1378
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-321-8218
Provider Business Mailing Address Fax Number:
708-321-8219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15475 S PARK AVE STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH HOLLAND
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60473-1378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-321-8218
Provider Business Practice Location Address Fax Number:
708-321-8219
Provider Enumeration Date:
09/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
OLANIYAN
Authorized Official First Name:
DEBO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
708-321-8218

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X , with the licence number:  4000478 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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