Provider Demographics
NPI:1558824607
Name:DIVINE PROVIDENCE INC
Entity Type:Organization
Organization Name:DIVINE PROVIDENCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MODUPE
Authorized Official - Middle Name:
Authorized Official - Last Name:IROROBEJE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-778-3072
Mailing Address - Street 1:11055 KILKERRAN CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-4356
Mailing Address - Country:US
Mailing Address - Phone:954-663-1759
Mailing Address - Fax:
Practice Address - Street 1:1729 E CHARLESTON BLVD STE F
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1986
Practice Address - Country:US
Practice Address - Phone:954-663-1759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-06
Last Update Date:2019-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies