Provider Demographics
NPI:1992217061
Name:DIVINE HEALTHCARE SERVICE CORP
Entity Type:Organization
Organization Name:DIVINE HEALTHCARE SERVICE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:EDITH
Authorized Official - Last Name:MALOKU
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:954-559-6045
Mailing Address - Street 1:15883 NW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-1602
Mailing Address - Country:US
Mailing Address - Phone:954-559-6045
Mailing Address - Fax:954-450-7975
Practice Address - Street 1:15883 NW 11TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028
Practice Address - Country:US
Practice Address - Phone:954-559-6045
Practice Address - Fax:954-450-7975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1691672363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty