Provider Demographics
NPI:1801384912
Name:DIVINE 5 SERVICES, LLC
Entity Type:Organization
Organization Name:DIVINE 5 SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELANTE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-217-1821
Mailing Address - Street 1:304 E CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2508
Mailing Address - Country:US
Mailing Address - Phone:770-217-1821
Mailing Address - Fax:
Practice Address - Street 1:304 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2508
Practice Address - Country:US
Practice Address - Phone:770-217-1821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA824625122OtherNON-MEDICAL