Provider Demographics
NPI:1518046622
Name:DIVINE MEDICAL EQUIPMENT SUPPLIES, INC.
Entity Type:Organization
Organization Name:DIVINE MEDICAL EQUIPMENT SUPPLIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:IFEANYI
Authorized Official - Last Name:IROEGBU
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT
Authorized Official - Phone:919-881-8068
Mailing Address - Street 1:1001 NAVAHO DR
Mailing Address - Street 2:SUITE 203-B
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7335
Mailing Address - Country:US
Mailing Address - Phone:919-881-8068
Mailing Address - Fax:919-881-8316
Practice Address - Street 1:1001 NAVAHO DR
Practice Address - Street 2:SUITE 203-B
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7335
Practice Address - Country:US
Practice Address - Phone:919-881-8068
Practice Address - Fax:919-881-8316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01191332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5806870001Medicare NSC