Provider Demographics
NPI:1952920795
Name:DIVINE MEDICAL LLC
Entity Type:Organization
Organization Name:DIVINE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:UMEOZOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-742-2442
Mailing Address - Street 1:13163 233RD ST # 1
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-1305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13163 233RD ST # 1
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-1305
Practice Address - Country:US
Practice Address - Phone:718-525-3347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-12
Last Update Date:2020-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02208982Medicaid