Healthcare Provider Details

I. General information

NPI: 1831631134
Provider Name (Legal Business Name): DIVINE INNOVATIONS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2016
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6646 S STAPLES ST STE 108
CORPUS CHRISTI TX
78413-5426
US

IV. Provider business mailing address

6537 S STAPLES ST SUITE 125 #442
CORPUS CHRISTI TX
78413-5418
US

V. Phone/Fax

Practice location:
  • Phone: 361-854-1460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number8519
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number8519
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8519
License Number StateTX

VIII. Authorized Official

Name: ASHLEY SETTERBERG
Title or Position: OWNER/MANAGER
Credential:
Phone: 361-854-1460