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General NPI Number Information
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NPI Number | 1073938049
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Entity Type | Organization
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Legal Business Name | DIVINE ENLIGHTENMENT HOLISTIC INC
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Dates
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Enumeration Date | 02/27/2014
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Last Update Date | 02/27/2014
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Provider Practice Location Address
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Address Line | 10722 ARROW RTE SUITE 520
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-4808
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Country | US
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Telephone | 888-706-8684
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 623
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City | UPLAND
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State | CA
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Zip | 91785-0623
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MASSAGE THERAPIST
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Name | NAKEIA IVERY
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Credential |
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Telephone | 888-706-8684
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 364SH1100X
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Taxonomy Name | Holistic Clinical Nurse Specialist
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License Number | 43368
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 43368
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License Number State | CA
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