1861712408 NPI number — DIVINE HEALTH SERVICES LLC

Table of content: (NPI 1861712408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861712408 NPI number — DIVINE HEALTH SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVINE HEALTH SERVICES LLC
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:
1861712408
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1111 807 NASHVILLE HWY STE 10
Provider Second Line Business Mailing Address:
STE 10
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
931-840-4119
Provider Business Mailing Address Fax Number:
931-840-4121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
807 NASHVILLE HWY. STE. 10
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-840-4119
Provider Business Practice Location Address Fax Number:
931-840-4121
Provider Enumeration Date:
06/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ESMOND
Authorized Official First Name:
WILLIE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
931-840-4119

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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