Provider Demographics
NPI: | 1023548948 |
---|---|
Name: | DIVINE PROSPERITY LLC |
Entity Type: | Organization |
Organization Name: | DIVINE PROSPERITY LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KISHORE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | KUMAR |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 855-541-2862 |
Mailing Address - Street 1: | 15317 GRAYSON DR |
Mailing Address - Street 2: | |
Mailing Address - City: | EDMOND |
Mailing Address - State: | OK |
Mailing Address - Zip Code: | 73013-2601 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 855-541-2862 |
Mailing Address - Fax: | 405-716-4808 |
Practice Address - Street 1: | 1104 E STATE HIGHWAY 152 UNIT 1 |
Practice Address - Street 2: | |
Practice Address - City: | MUSTANG |
Practice Address - State: | OK |
Practice Address - Zip Code: | 73064-5116 |
Practice Address - Country: | US |
Practice Address - Phone: | 405-563-3998 |
Practice Address - Fax: | 405-563-3998 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-06-13 |
Last Update Date: | 2017-06-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OK | 25877 | 208M00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Single Specialty |