Provider Demographics
NPI:1871859918
Name:DIVINE FAMILY EYE CARE, LLC
Entity Type:Organization
Organization Name:DIVINE FAMILY EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIVINE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-712-2333
Mailing Address - Street 1:1347 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901
Mailing Address - Country:US
Mailing Address - Phone:573-712-2333
Mailing Address - Fax:573-712-2433
Practice Address - Street 1:1347 N. WESTWOOD BLVD.
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-429-1918
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010020558152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty