Provider Demographics
NPI:1518719483
Name:DIVINITY HEALTHCARE SERVICES, LLC
Entity Type:Organization
Organization Name:DIVINITY HEALTHCARE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EKARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WAFER-MENDENHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-265-4542
Mailing Address - Street 1:504 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:LA
Mailing Address - Zip Code:71040-3915
Mailing Address - Country:US
Mailing Address - Phone:318-265-4542
Mailing Address - Fax:
Practice Address - Street 1:504 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:LA
Practice Address - Zip Code:71040-3915
Practice Address - Country:US
Practice Address - Phone:318-265-4542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:-
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center