Provider Demographics
NPI:1841280104
Name:DIVINITYCARES, INCORPORATION
Entity type:Organization
Organization Name:DIVINITYCARES, INCORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:EDIWNA
Authorized Official - Middle Name:HARMON
Authorized Official - Last Name:BUSHNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-990-0122
Mailing Address - Street 1:1202 COMMON ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5254
Mailing Address - Country:US
Mailing Address - Phone:337-990-0122
Mailing Address - Fax:337-990-0124
Practice Address - Street 1:1202 COMMON ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5254
Practice Address - Country:US
Practice Address - Phone:337-990-0122
Practice Address - Fax:337-990-0124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization