Provider Demographics
NPI:1831631134
Name:DIVINE INNOVATIONS PLLC
Entity type:Organization
Organization Name:DIVINE INNOVATIONS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SETTERBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-854-1460
Mailing Address - Street 1:6537 S STAPLES ST
Mailing Address - Street 2:SUITE 125 #442
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6646 S STAPLES ST STE 108
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-5426
Practice Address - Country:US
Practice Address - Phone:361-854-1460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-17
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8519152WC0802X, 332H00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty