Provider Demographics
NPI:1881901668
Name:DIVINE DIAGNOSTIC COMPANY
Entity type:Organization
Organization Name:DIVINE DIAGNOSTIC COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SUHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALAKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-713-8397
Mailing Address - Street 1:5005 E 14 MILE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-6533
Mailing Address - Country:US
Mailing Address - Phone:586-795-3815
Mailing Address - Fax:586-620-6062
Practice Address - Street 1:5005 E 14 MILE RD STE 100
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-6533
Practice Address - Country:US
Practice Address - Phone:586-795-3815
Practice Address - Fax:586-620-6062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
0E03743OtherBC
MI1881901668Medicaid
MIMI5342Medicare PIN