Provider Demographics
NPI:1891086914
Name:DIVINE MEDICAL SUPPLY, INCORPORATED
Entity Type:Organization
Organization Name:DIVINE MEDICAL SUPPLY, INCORPORATED
Other - Org Name:DIVINE MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FEMI
Authorized Official - Middle Name:O
Authorized Official - Last Name:ABATAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-225-4762
Mailing Address - Street 1:285 S GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-2908
Mailing Address - Country:US
Mailing Address - Phone:714-457-2049
Mailing Address - Fax:714-930-9435
Practice Address - Street 1:285 S GILBERT ST
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-2908
Practice Address - Country:US
Practice Address - Phone:714-457-2049
Practice Address - Fax:714-930-9435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-23
Last Update Date:2011-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No282E00000XHospitalsLong Term Care Hospital