Healthcare Provider Details

I. General information

NPI: 1538457346
Provider Name (Legal Business Name): DIVINE MEDICAL SUPPLIES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 07/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7070 UPPER 157TH ST W
APPLE VALLEY MN
55124-5121
US

IV. Provider business mailing address

7070 UPPER 157TH ST W
APPLE VALLEY MN
55124-5121
US

V. Phone/Fax

Practice location:
  • Phone: 714-225-4762
  • Fax: 714-930-9435
Mailing address:
  • Phone: 714-225-4762
  • Fax: 714-930-9435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. FEMI ABATAN
Title or Position: PRESIDENT
Credential:
Phone: 714-225-4762