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General NPI Number Information
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NPI Number | 1881350056
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Entity Type | Organization
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Legal Business Name | DIVINE SURGICAL SERVICES LLC
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Dates
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Enumeration Date | 11/12/2021
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Last Update Date | 01/25/2022
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Provider Practice Location Address
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Address Line | 110 NINA LN
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City | STAFFORD
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State | TX
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Zip | 77477-4647
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Country | US
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Telephone | 800-801-9297
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 97
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City | STAFFORD
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State | TX
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Zip | 77497-0097
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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 | OWNER/ CEO
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Name | ZEMORAH ISRAEL
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Credential | LSA
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Telephone | 800-801-9297
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State |
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