Healthcare Provider Details

I. General information

NPI: 1841280104
Provider Name (Legal Business Name): DIVINITYCARES, INCORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 COMMON ST
LAKE CHARLES LA
70601-5254
US

IV. Provider business mailing address

1202 COMMON ST
LAKE CHARLES LA
70601-5254
US

V. Phone/Fax

Practice location:
  • Phone: 337-990-0122
  • Fax: 337-990-0124
Mailing address:
  • Phone: 337-990-0122
  • Fax: 337-990-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number StateLA

VIII. Authorized Official

Name: MRS. EDIWNA HARMON BUSHNELL
Title or Position: CEO
Credential:
Phone: 337-990-0122