Healthcare Provider Details

I. General information

NPI: 1477276368
Provider Name (Legal Business Name): DIVINE THERAPY SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 TURNER ST
DEWITT MI
48820-9605
US

IV. Provider business mailing address

607 TURNER ST
DEWITT MI
48820-9605
US

V. Phone/Fax

Practice location:
  • Phone: 231-233-2480
  • Fax:
Mailing address:
  • Phone: 231-233-2480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: JERROLYNN JUSTUSSON
Title or Position: PRESIDENT
Credential:
Phone: 800-743-0396