Healthcare Provider Details

I. General information

NPI: 1033309968
Provider Name (Legal Business Name): DIVINE GRACE MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 BLOOMFIELD AVE
NUTLEY NJ
07110-3135
US

IV. Provider business mailing address

159 BLOOMFIELD AVE
NUTLEY NJ
07110-3135
US

V. Phone/Fax

Practice location:
  • Phone: 973-235-1772
  • Fax: 973-235-1774
Mailing address:
  • Phone: 973-235-1772
  • Fax: 973-235-1774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
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: MARCIANO FIGUEROA
Title or Position: PHYSICIAN
Credential:
Phone: 973-235-1772