Provider Demographics
NPI:1629843016
Name:DIVINE MEDICAL SERVICES
Entity Type:Organization
Organization Name:DIVINE MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INDEPENDENT PRACTITINER PA-C
Authorized Official - Prefix:DR
Authorized Official - First Name:CHINELO
Authorized Official - Middle Name:J
Authorized Official - Last Name:OKONKWO
Authorized Official - Suffix:
Authorized Official - Credentials:DMS-PAC
Authorized Official - Phone:410-905-5640
Mailing Address - Street 1:207 CASTLEWELLAN CT
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-2906
Mailing Address - Country:US
Mailing Address - Phone:804-481-1159
Mailing Address - Fax:804-203-1919
Practice Address - Street 1:700 S SYCAMORE ST STE 15
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-5804
Practice Address - Country:US
Practice Address - Phone:804-481-1159
Practice Address - Fax:804-203-1919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center