Healthcare Provider Details

I. General information

NPI: 1609606417
Provider Name (Legal Business Name): DIVINE AFC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 W BOYLSTON ST STE 2
WORCESTER MA
01606-3074
US

IV. Provider business mailing address

716 W BOYLSTON ST STE 2
WORCESTER MA
01606-3074
US

V. Phone/Fax

Practice location:
  • Phone: 508-444-0955
  • Fax:
Mailing address:
  • Phone: 508-444-0955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: RATNA BALAGANI
Title or Position: MANAGER
Credential:
Phone: 508-368-4358