Provider Demographics
NPI:1275092991
Name:DIVINE, JOHNNY LEO
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:LEO
Last Name:DIVINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41
Mailing Address - Street 2:
Mailing Address - City:GOLDEN CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64748
Mailing Address - Country:US
Mailing Address - Phone:417-262-2524
Mailing Address - Fax:
Practice Address - Street 1:507 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GOLDEN CITY
Practice Address - State:MO
Practice Address - Zip Code:64748
Practice Address - Country:US
Practice Address - Phone:417-262-2524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment