Provider Demographics
NPI:1821656901
Name:DIVINE WELLNESS INC
Entity Type:Organization
Organization Name:DIVINE WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:OLUSEGUN
Authorized Official - Middle Name:ADEWALE
Authorized Official - Last Name:SOFOWOTE
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:443-272-2207
Mailing Address - Street 1:9633 LIBERTY RD STE K
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-2435
Mailing Address - Country:US
Mailing Address - Phone:443-272-2207
Mailing Address - Fax:
Practice Address - Street 1:9633 LIBERTY RD STE K
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-2435
Practice Address - Country:US
Practice Address - Phone:443-272-2207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health