MEDICARE: DIVINE HEALING HEALTH SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1134594591
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE HEALING HEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	2608 WHITE OAK RD
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-5341
Country	:	US
Telephone Number	:	702-351-8798
Fax Number	:

Provider Business Practice Location Address
First Line	:	2608 WHITE OAK RD
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-5341
Country	:	US
Telephone Number	:	702-351-8798
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DARRYL J ALLEN
Credential	:
Telephone Number	:	702-205-7515

Provider Enumeration Date	:	12/09/2015
Last Update Date	:	12/09/2015

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