Healthcare Provider Details

I. General information

NPI: 1073938049
Provider Name (Legal Business Name): DIVINE ENLIGHTENMENT HOLISTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2014
Last Update Date: 02/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10722 ARROW RTE SUITE 520
RANCHO CUCAMONGA CA
91730-4808
US

IV. Provider business mailing address

PO BOX 623
UPLAND CA
91785-0623
US

V. Phone/Fax

Practice location:
  • Phone: 888-706-8684
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number43368
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code364SH1100X
TaxonomyHolistic Clinical Nurse Specialist
License Number43368
License Number StateCA

VIII. Authorized Official

Name: NAKEIA IVERY
Title or Position: MASSAGE THERAPIST
Credential:
Phone: 888-706-8684