Provider Demographics
NPI:1477276368
Name:DIVINE THERAPY SERVICES INC
Entity Type:Organization
Organization Name:DIVINE THERAPY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERROLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTUSSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-743-0396
Mailing Address - Street 1:607 TURNER ST
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-9605
Mailing Address - Country:US
Mailing Address - Phone:231-233-2480
Mailing Address - Fax:
Practice Address - Street 1:607 TURNER ST
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820-9605
Practice Address - Country:US
Practice Address - Phone:231-233-2480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty