Provider Demographics
NPI:1134657208
Name:DIVINE NUTRITION SERVICE
Entity Type:Organization
Organization Name:DIVINE NUTRITION SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:GENENE
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:RDLD
Authorized Official - Phone:314-732-2302
Mailing Address - Street 1:2080 CORDOBA DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-2807
Mailing Address - Country:US
Mailing Address - Phone:314-732-2302
Mailing Address - Fax:
Practice Address - Street 1:2080 CORDOBA DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-2807
Practice Address - Country:US
Practice Address - Phone:314-732-2302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-01
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1134657208Medicaid