Provider Demographics
NPI:1730651571
Name:DIVINE SUPPORTS
Entity Type:Organization
Organization Name:DIVINE SUPPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MILLICENT
Authorized Official - Middle Name:
Authorized Official - Last Name:IWUCHUKWU
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:615-594-7139
Mailing Address - Street 1:2131 MURFREESBORO PIKE STE 211
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37217-6316
Mailing Address - Country:US
Mailing Address - Phone:615-432-2917
Mailing Address - Fax:615-250-4772
Practice Address - Street 1:2131 MURFREESBORO PIKE STE 211
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37217-6316
Practice Address - Country:US
Practice Address - Phone:615-432-2917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
05727485OtherAMERIGROUP