Provider Demographics
NPI:1992397715
Name:DIVINITY HEALTH & WELLNESS PLLC
Entity Type:Organization
Organization Name:DIVINITY HEALTH & WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEXTERIA
Authorized Official - Middle Name:REBECCA
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:336-225-1079
Mailing Address - Street 1:2671 DALLAS DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-4446
Mailing Address - Country:US
Mailing Address - Phone:769-218-8891
Mailing Address - Fax:
Practice Address - Street 1:2671 DALLAS DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-4446
Practice Address - Country:US
Practice Address - Phone:769-218-8891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-04
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory