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General NPI Number Information
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NPI Number | 1891251245
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Entity Type | Organization
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Legal Business Name | DIVINE HEALTH AND WELLNESS
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Dates
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Enumeration Date | 02/11/2019
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Last Update Date | 06/18/2020
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Provider Practice Location Address
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Address Line | 2045 DUTCHESS RD
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City | LITHIA SPRINGS
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State | GA
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Zip | 30122-2312
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Country | US
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Telephone | 770-356-9703
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Fax |
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Provider Business Mailing Address
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Address Line | 2045 DUTCHESS RD
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City | LITHIA SPRINGS
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State | GA
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Zip | 30122-2312
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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
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Name | TABITHA MACON
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Credential |
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Telephone | 770-356-9703
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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