Provider Demographics
NPI:1306224977
Name:DIVINE DRIVE, INC
Entity Type:Organization
Organization Name:DIVINE DRIVE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-398-2370
Mailing Address - Street 1:1256 W JEFFERSON ST
Mailing Address - Street 2:104
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6886
Mailing Address - Country:US
Mailing Address - Phone:815-582-4711
Mailing Address - Fax:815-846-8445
Practice Address - Street 1:1256 W JEFFERSON ST
Practice Address - Street 2:104
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6886
Practice Address - Country:US
Practice Address - Phone:815-582-4711
Practice Address - Fax:815-846-8445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)