Provider Demographics
NPI:1790592632
Name:DIVINE GLOW HEALTH LLC
Entity type:Organization
Organization Name:DIVINE GLOW HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:
Authorized Official - Last Name:EBO
Authorized Official - Suffix:
Authorized Official - Credentials:NP, DNP
Authorized Official - Phone:832-428-8393
Mailing Address - Street 1:14090 SOUTHWEST FWY STE 300
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3679
Mailing Address - Country:US
Mailing Address - Phone:800-645-0865
Mailing Address - Fax:800-645-0866
Practice Address - Street 1:14090 SOUTHWEST FWY STE 300
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3679
Practice Address - Country:US
Practice Address - Phone:800-645-0865
Practice Address - Fax:800-645-0866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty