Provider Demographics
NPI:1568092799
Name:DIVINE WELLNESS
Entity Type:Organization
Organization Name:DIVINE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ERMA
Authorized Official - Middle Name:
Authorized Official - Last Name:MINCEY
Authorized Official - Suffix:
Authorized Official - Credentials:NMT, LMT
Authorized Official - Phone:404-729-0637
Mailing Address - Street 1:3469 LAWRENCEVILLE HWY STE 201
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5866
Mailing Address - Country:US
Mailing Address - Phone:404-729-0637
Mailing Address - Fax:
Practice Address - Street 1:3469 LAWRENCEVILLE HWY STE 201
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5866
Practice Address - Country:US
Practice Address - Phone:404-729-0637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty