Provider Demographics
NPI:1477253425
Name:DIVINE DESTINY ENTERPRISE LLC
Entity Type:Organization
Organization Name:DIVINE DESTINY ENTERPRISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHELATHUM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-394-6573
Mailing Address - Street 1:225 MARKET PLACE CONNECTOR # 1144
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3542
Mailing Address - Country:US
Mailing Address - Phone:678-929-1123
Mailing Address - Fax:
Practice Address - Street 1:670 BIRKDALE DR
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-2924
Practice Address - Country:US
Practice Address - Phone:678-394-6573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)