Provider Demographics
NPI:1336348853
Name:DIVINE HEALTHCARE SERVICES,INC
Entity Type:Organization
Organization Name:DIVINE HEALTHCARE SERVICES,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BENNETH
Authorized Official - Middle Name:IFEANYICHUKWU
Authorized Official - Last Name:OKORIE
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR OF OPTOMETRY,
Authorized Official - Phone:310-227-3940
Mailing Address - Street 1:405 W MANCHESTER BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1196
Mailing Address - Country:US
Mailing Address - Phone:310-672-3820
Mailing Address - Fax:
Practice Address - Street 1:405 W MANCHESTER BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1196
Practice Address - Country:US
Practice Address - Phone:310-672-3820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health