Provider Demographics
NPI:1790428555
Name:DIVINE HEALTH MEDICAL AND SPA LLC
Entity Type:Organization
Organization Name:DIVINE HEALTH MEDICAL AND SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EDUCATOR
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:OWIE
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:240-437-9997
Mailing Address - Street 1:12406 BUCKLEY DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-2017
Mailing Address - Country:US
Mailing Address - Phone:240-437-9997
Mailing Address - Fax:240-669-6079
Practice Address - Street 1:11119 ROCKVILLE PIKE STE 320
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3143
Practice Address - Country:US
Practice Address - Phone:240-669-6598
Practice Address - Fax:240-669-6079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-19
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty