Provider Demographics
NPI:1073938049
Name:DIVINE ENLIGHTENMENT HOLISTIC INC
Entity Type:Organization
Organization Name:DIVINE ENLIGHTENMENT HOLISTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NAKEIA
Authorized Official - Middle Name:
Authorized Official - Last Name:IVERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-706-8684
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91785-0623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10722 ARROW RTE
Practice Address - Street 2:SUITE 520
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4808
Practice Address - Country:US
Practice Address - Phone:888-706-8684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43368225700000X, 364SH1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No364SH1100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHolisticGroup - Single Specialty