Provider Demographics
NPI:1396091773
Name:DIVINE CHIROPRACTIC HEALTH AND WELLNESS PLLC
Entity type:Organization
Organization Name:DIVINE CHIROPRACTIC HEALTH AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DENSTEDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:863-670-5137
Mailing Address - Street 1:1820 E COUNTY ROAD 540A
Mailing Address - Street 2:WELLNESS
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3737
Mailing Address - Country:US
Mailing Address - Phone:863-670-5137
Mailing Address - Fax:863-299-3016
Practice Address - Street 1:1820 E COUNTY ROAD 540A
Practice Address - Street 2:WELLNESS
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3737
Practice Address - Country:US
Practice Address - Phone:863-670-5137
Practice Address - Fax:863-299-3016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-03
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10414261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center