Provider Demographics
NPI:1093324527
Name:DEVINE CONCIERGE MEDICINE, LLC
Entity Type:Organization
Organization Name:DEVINE CONCIERGE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-554-5626
Mailing Address - Street 1:104 SOUTH WAYNE AVENUE, P.O. BOX #279
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087
Mailing Address - Country:US
Mailing Address - Phone:610-554-5626
Mailing Address - Fax:
Practice Address - Street 1:165 RIDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-2846
Practice Address - Country:US
Practice Address - Phone:610-554-5626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-30
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty