=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225815921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINE HOLISTIC CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2023
-----------------------------------------------------
Last Update Date | 09/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13532 1/2 CHADRON AVE
-----------------------------------------------------
City | HAWTHORNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90250-7822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-200-9015
-----------------------------------------------------
Fax | 855-214-7520
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13532 1/2 CHADRON AVE
-----------------------------------------------------
City | HAWTHORNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90250-7822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-200-9015
-----------------------------------------------------
Fax | 855-214-7520
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HENRIETHA IWOBI
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 424-200-9015
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------