Provider Demographics
NPI:1376269449
Name:DIVINE HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:DIVINE HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIE PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:TONY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:954-832-7475
Mailing Address - Street 1:2820 NE 214TH ST STE 828
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1270
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2820 NE 214TH ST STE 828
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1270
Practice Address - Country:US
Practice Address - Phone:954-832-7475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty