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General NPI Number Information
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NPI Number | 1619540572
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Entity Type | Organization
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Legal Business Name | DIVA RESOURCE CONNECTION INC
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Dates
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Enumeration Date | 07/20/2021
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Last Update Date | 07/20/2021
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Provider Practice Location Address
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Address Line | 4807 W HARRISON ST
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City | CHICAGO
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State | IL
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Zip | 60644-5130
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Country | US
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Telephone | 630-303-8247
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Fax |
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Provider Business Mailing Address
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Address Line | 2013 S 13TH AVE
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City | MAYWOOD
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State | IL
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Zip | 60153-3129
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Country | US
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Telephone | 630-303-8247
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRYANDIE WALKER
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Credential |
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Telephone | 630-303-8247
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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