Provider Demographics
NPI:1922650100
Name:KUJA, DIVINE LOVALA
Entity Type:Individual
Prefix:
First Name:DIVINE
Middle Name:LOVALA
Last Name:KUJA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S GREAT SOUTHWEST PKWY STE 106
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-1057
Mailing Address - Country:US
Mailing Address - Phone:214-412-2528
Mailing Address - Fax:
Practice Address - Street 1:601 S GREAT SOUTHWEST PKWY STE 106
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1057
Practice Address - Country:US
Practice Address - Phone:214-412-2528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1236233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist