Healthcare Provider Details

I. General information

NPI: 1699147116
Provider Name (Legal Business Name): DIVINE AGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 ULMERTON RD SUITE 19
CLEARWATER FL
33762-2282
US

IV. Provider business mailing address

2325 ULMERTON RD SUITE 19
CLEARWATER FL
33762-2282
US

V. Phone/Fax

Practice location:
  • Phone: 727-271-1984
  • Fax: 727-210-3036
Mailing address:
  • Phone: 727-271-1984
  • Fax: 727-210-3036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PARVINDER S KAINTH
Title or Position: OWNER
Credential:
Phone: 727-271-1984