Provider Demographics
NPI:1982012241
Name:DEVINE NUTRITION INC
Entity Type:Organization
Organization Name:DEVINE NUTRITION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MS RD CSSD LDN
Authorized Official - Phone:708-612-0876
Mailing Address - Street 1:6521 CHARLESTON ST
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-2626
Mailing Address - Country:US
Mailing Address - Phone:708-612-0876
Mailing Address - Fax:
Practice Address - Street 1:6811 167TH ST STE 6
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2501
Practice Address - Country:US
Practice Address - Phone:708-612-0876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-30
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164004722261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center