Provider Demographics
NPI:1336992437
Name:DIVINITY DIAGNOSTIC & WELLNESS INC
Entity Type:Organization
Organization Name:DIVINITY DIAGNOSTIC & WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATEDA
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:CMA
Authorized Official - Phone:504-274-6023
Mailing Address - Street 1:2002 20TH ST STE B202
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70062-4403
Mailing Address - Country:US
Mailing Address - Phone:504-667-3641
Mailing Address - Fax:
Practice Address - Street 1:2002 20TH ST STE B202
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70062-4403
Practice Address - Country:US
Practice Address - Phone:504-667-3641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center