Provider Demographics
NPI:1790169548
Name:SHILOH C DIVINE HEALTHCARE SERVICE
Entity Type:Organization
Organization Name:SHILOH C DIVINE HEALTHCARE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:MRS
Authorized Official - First Name:EMILIANA
Authorized Official - Middle Name:OMAWUMI
Authorized Official - Last Name:EZECHIGBO
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:832-212-4739
Mailing Address - Street 1:14406 PARKESGATE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083-5789
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14406 PARKESGATE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-5789
Practice Address - Country:US
Practice Address - Phone:832-212-4739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-11
Last Update Date:2015-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128425363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty