Provider Demographics
NPI:1790536142
Name:DIVINE REDEMPTION LLC
Entity Type:Organization
Organization Name:DIVINE REDEMPTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:DIVINE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:417-296-4140
Mailing Address - Street 1:16105 S HIGHWAY 39
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:MO
Mailing Address - Zip Code:65785-8391
Mailing Address - Country:US
Mailing Address - Phone:417-296-4140
Mailing Address - Fax:417-326-0022
Practice Address - Street 1:112 W BROADWAY
Practice Address - Street 2:SUITE A
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613
Practice Address - Country:US
Practice Address - Phone:417-296-4140
Practice Address - Fax:417-326-0022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty