Provider Demographics
NPI:1609444728
Name:DIVINE ORTHOPEDICS AND SPINE LLC
Entity Type:Organization
Organization Name:DIVINE ORTHOPEDICS AND SPINE LLC
Other - Org Name:DIVINE ORTHOPEDICS AND SPINE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KUPPINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-699-6373
Mailing Address - Street 1:1006 WHITE DR
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33483-6527
Mailing Address - Country:US
Mailing Address - Phone:561-699-6373
Mailing Address - Fax:
Practice Address - Street 1:111 E MONUMENT AVE UNIT 515
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5779
Practice Address - Country:US
Practice Address - Phone:561-908-3200
Practice Address - Fax:561-790-8553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty