1861712408 NPI number — DIVINE HEALTH SERVICES LLC

Table of Contents

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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