=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902646292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINE ACCESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2024
-----------------------------------------------------
Last Update Date | 06/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 167 GILLIFLOWER PARK
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024-6456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-983-4084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 990 PEACHTREE INDUSTRIAL BLVD P.O.BOX 938
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024-9998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-983-4048
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. UDU OLADEINDE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-983-4048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------