Healthcare Provider Details

I. General information

NPI: 1902646292
Provider Name (Legal Business Name): DIVINE ACCESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2024
Last Update Date: 06/02/2024
Certification Date: 06/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 GILLIFLOWER PARK
SUWANEE GA
30024-6456
US

IV. Provider business mailing address

990 PEACHTREE INDUSTRIAL BLVD P.O.BOX 938
SUWANEE GA
30024-9998
US

V. Phone/Fax

Practice location:
  • Phone: 770-983-4084
  • Fax:
Mailing address:
  • Phone: 770-983-4048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. UDU OLADEINDE
Title or Position: MANAGER
Credential:
Phone: 770-983-4048