Provider Demographics
NPI:1033359070
Name:DIVINE CHIROPRACTIC AND WELLNESS CENTER
Entity Type:Organization
Organization Name:DIVINE CHIROPRACTIC AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEDDEH
Authorized Official - Middle Name:A
Authorized Official - Last Name:KORVAH-REED
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:614-222-0019
Mailing Address - Street 1:67 PARSONS AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-3978
Mailing Address - Country:US
Mailing Address - Phone:614-222-0019
Mailing Address - Fax:614-222-0019
Practice Address - Street 1:629 S OHIO AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2743
Practice Address - Country:US
Practice Address - Phone:614-477-8140
Practice Address - Fax:614-258-3811
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVINE CHIROPRACTIC AND WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-04
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3769111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2805503Medicaid
OHKO4222021Medicare PIN