Provider Demographics
NPI:1902646292
Name:DIVINE ACCESS LLC
Entity type:Organization
Organization Name:DIVINE ACCESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:UDU
Authorized Official - Middle Name:
Authorized Official - Last Name:OLADEINDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-983-4048
Mailing Address - Street 1:990 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:P.O.BOX 938
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-9998
Mailing Address - Country:US
Mailing Address - Phone:770-983-4048
Mailing Address - Fax:
Practice Address - Street 1:167 GILLIFLOWER PARK
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6456
Practice Address - Country:US
Practice Address - Phone:770-983-4084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-25
Last Update Date:2024-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty