Provider Demographics
NPI:1235756313
Name:DIVINE DESTINY VIRTUAL HEALTH
Entity Type:Organization
Organization Name:DIVINE DESTINY VIRTUAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOUELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRITCHETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:407-732-0720
Mailing Address - Street 1:2631A NW 41ST ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-6628
Mailing Address - Country:US
Mailing Address - Phone:407-732-0720
Mailing Address - Fax:855-604-0918
Practice Address - Street 1:2631A NW 41ST ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6628
Practice Address - Country:US
Practice Address - Phone:407-732-2070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1104161017OtherCOMMERCIAL
FL1104161017OtherCOMMERCIAL
FL1104161017Medicaid
PA1104161017Medicaid