Provider Demographics
NPI:1700258787
Name:DIVINE CHIROPRACTIC AND REHABILITATION LLC
Entity Type:Organization
Organization Name:DIVINE CHIROPRACTIC AND REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:T
Authorized Official - Last Name:ANKRAH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:240-863-3710
Mailing Address - Street 1:344 UNIVERSITY BLVD W STE 210
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-1970
Mailing Address - Country:US
Mailing Address - Phone:240-863-3710
Mailing Address - Fax:301-844-5724
Practice Address - Street 1:344 UNIVERSITY BLVD W STE 210
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-1970
Practice Address - Country:US
Practice Address - Phone:240-863-3710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-29
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS03770111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty