MEDICARE: DIVINE HEALTH AND WELLNESS CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	103K00000X	NV

General Provider Information

NPI Number	:	1194175745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE HEALTH AND WELLNESS CORP

Provider Business Mailing Address
First Line	:	6136 WARM RIVER RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-1757
Country	:	US
Telephone Number	:	702-236-7529
Fax Number	:

Provider Business Practice Location Address
First Line	:	6136 WARM RIVER RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-1757
Country	:	US
Telephone Number	:	702-236-7529
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MS. ADESUWA OSAZUWA
Credential	:
Telephone Number	:	702-236-7529

Provider Enumeration Date	:	06/14/2016
Last Update Date	:	06/14/2016

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Directions to “DIVINE HEALTH AND WELLNESS CORP ” Practice Location

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