Provider Demographics
NPI:1053828244
Name:DEVINE FAMILY CARE PRACTICE LLC
Entity Type:Organization
Organization Name:DEVINE FAMILY CARE PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MBAH
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:410-963-9577
Mailing Address - Street 1:7131 LIBERTY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:GWYNN OAK
Mailing Address - State:MD
Mailing Address - Zip Code:21207-4580
Mailing Address - Country:US
Mailing Address - Phone:410-963-9577
Mailing Address - Fax:
Practice Address - Street 1:7131 LIBERTY RD STE 100
Practice Address - Street 2:
Practice Address - City:GWYNN OAK
Practice Address - State:MD
Practice Address - Zip Code:21207-4580
Practice Address - Country:US
Practice Address - Phone:410-963-9577
Practice Address - Fax:443-200-5261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-09
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty