Healthcare Provider Details

I. General information

NPI: 1629829262
Provider Name (Legal Business Name): DIVINE DIETS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8405 PAMELA WAY N/A
LAUREL MD
20723
US

IV. Provider business mailing address

8405 PAMELA WAY N/A
LAUREL MD
20723
US

V. Phone/Fax

Practice location:
  • Phone: 443-761-9890
  • Fax:
Mailing address:
  • Phone: 443-761-9890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: DR. DIVYA L SELVAKUMAR
Title or Position: CO-OWNER
Credential: PHD, RD
Phone: 443-761-9890