Provider Demographics
NPI:1679190268
Name:DEVINE' WELLNESS & SPA LLC
Entity Type:Organization
Organization Name:DEVINE' WELLNESS & SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ LICENSED MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DEVON
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLEMAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:301-898-6420
Mailing Address - Street 1:1369 MAIN ST STE 6
Mailing Address - Street 2:
Mailing Address - City:DUNEDIN
Mailing Address - State:FL
Mailing Address - Zip Code:34698-6246
Mailing Address - Country:US
Mailing Address - Phone:301-898-6420
Mailing Address - Fax:
Practice Address - Street 1:1369 MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:DUNEDIN
Practice Address - State:FL
Practice Address - Zip Code:34698-6246
Practice Address - Country:US
Practice Address - Phone:301-898-6420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty