Provider Demographics
NPI:1649706227
Name:DIVINE INTEGRITY ALLIED HEALTHCARE SERVICES
Entity type:Organization
Organization Name:DIVINE INTEGRITY ALLIED HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:POLK
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, RN
Authorized Official - Phone:432-889-2666
Mailing Address - Street 1:PO BOX 9732
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79708-9732
Mailing Address - Country:US
Mailing Address - Phone:432-889-2666
Mailing Address - Fax:
Practice Address - Street 1:4738 BEDFORD AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79703-4535
Practice Address - Country:US
Practice Address - Phone:432-889-2666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization