Provider Demographics
NPI:1306204623
Name:DIVINE LIFE HEALTH CENTER LLC
Entity Type:Organization
Organization Name:DIVINE LIFE HEALTH CENTER LLC
Other - Org Name:ESSENTIAL CHIROPRACTIC LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-877-1696
Mailing Address - Street 1:2200 PREMIER RESORT BLVD UNIT A
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-9203
Mailing Address - Country:US
Mailing Address - Phone:843-907-3594
Mailing Address - Fax:843-390-2379
Practice Address - Street 1:2200 PREMIER RESORT BLVD UNIT A
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-9203
Practice Address - Country:US
Practice Address - Phone:843-877-1696
Practice Address - Fax:843-390-2379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-01
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDC4046111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6270Medicare PIN