Provider Demographics
NPI:1104452804
Name:DIVINE DERMATOLOGY AND SURGICAL INSTITUTE, PLLC
Entity type:Organization
Organization Name:DIVINE DERMATOLOGY AND SURGICAL INSTITUTE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:DIVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-286-2668
Mailing Address - Street 1:1327 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-8059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1327 EAGLE DR
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-8059
Practice Address - Country:US
Practice Address - Phone:970-286-2668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVINE DERMATOLOGY AND SURGICAL INSTITUTE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-14
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty