Provider Demographics
NPI:1477111383
Name:DIVINE LIFE HEALTH SERVICES, PA
Entity Type:Organization
Organization Name:DIVINE LIFE HEALTH SERVICES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:KREULEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:863-446-2347
Mailing Address - Street 1:6040 BAY LN
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33876-6401
Mailing Address - Country:US
Mailing Address - Phone:863-446-2347
Mailing Address - Fax:
Practice Address - Street 1:249 US HIGHWAY 27 N
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-2132
Practice Address - Country:US
Practice Address - Phone:863-446-2347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty