MEDICARE: DIVINE DESTINY ENTERPRISE LLC

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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1477253425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE DESTINY ENTERPRISE LLC

Provider Business Mailing Address
First Line	:	225 MARKET PLACE CONNECTOR # 1144
Second Line	:
City	:	PEACHTREE CITY
State	:	GA
Zip	:	30269-3542
Country	:	US
Telephone Number	:	678-929-1123
Fax Number	:

Provider Business Practice Location Address
First Line	:	670 BIRKDALE DR
Second Line	:
City	:	FAIRBURN
State	:	GA
Zip	:	30213-2924
Country	:	US
Telephone Number	:	678-394-6573
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	SHELATHUM MOORE
Credential	:
Telephone Number	:	678-394-6573

Provider Enumeration Date	:	03/08/2023
Last Update Date	:	03/08/2023

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Directions to “DIVINE DESTINY ENTERPRISE LLC ” Practice Location

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