Healthcare Provider Details

I. General information

NPI: 1952705469
Provider Name (Legal Business Name): DIVINE GENESIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2014
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10164 RIVERSTONE DR
PARKER CO
80134-9164
US

IV. Provider business mailing address

10164 RIVERSTONE DR
PARKER CO
80134-9164
US

V. Phone/Fax

Practice location:
  • Phone: 720-675-8343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateCO

VIII. Authorized Official

Name: KRYSTAL CLEAVER
Title or Position: OWNER, DOULA
Credential: CLD, HCHD
Phone: 720-675-8343