Provider Demographics
NPI:1871249193
Name:DIVERGENT DIRECT PRIMARY CARE
Entity Type:Organization
Organization Name:DIVERGENT DIRECT PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TETSOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:TONWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-734-2444
Mailing Address - Street 1:1011 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-1201
Mailing Address - Country:US
Mailing Address - Phone:302-734-2444
Mailing Address - Fax:302-493-5254
Practice Address - Street 1:1011 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1201
Practice Address - Country:US
Practice Address - Phone:302-734-2444
Practice Address - Fax:302-493-5254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No251S00000XAgenciesCommunity/Behavioral Health
No332900000XSuppliersNon-Pharmacy Dispensing Site
No347C00000XTransportation ServicesPrivate Vehicle