1629461207 NPI number — DIVINE MEDICAL EQUIPMENT SUPPLY COMPANY

Table of content: TAMMY SUE JURGESS NP (NPI 1003464165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629461207 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:
Provider Other Organization Name Type Code:
6
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:
1629461207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/09/2025
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
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
SOUTH HOLLAND
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60473-1328
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:
1461 RING RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALUMET CITY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60409-5459
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:
03/06/2015

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: 253Z00000X , 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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