Provider Demographics
NPI:1588230734
Name:DIVINE MEDIC TRANSPORT
Entity Type:Organization
Organization Name:DIVINE MEDIC TRANSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KADIATU
Authorized Official - Middle Name:
Authorized Official - Last Name:DUMBUYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-432-6533
Mailing Address - Street 1:13661 CRIDERCREST PL APT 204
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-1989
Mailing Address - Country:US
Mailing Address - Phone:571-432-6533
Mailing Address - Fax:
Practice Address - Street 1:13661 CRIDERCREST PL APT 204
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-1989
Practice Address - Country:US
Practice Address - Phone:571-432-6533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)