MEDICARE: DIVINE PROVIDENCE INC

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1558824607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE PROVIDENCE INC

Provider Business Mailing Address
First Line	:	11055 KILKERRAN CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89141-4356
Country	:	US
Telephone Number	:	954-663-1759
Fax Number	:

Provider Business Practice Location Address
First Line	:	1729 E CHARLESTON BLVD STE F
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-1986
Country	:	US
Telephone Number	:	954-663-1759
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. MODUPE IROROBEJE
Credential	:
Telephone Number	:	702-778-3072

Provider Enumeration Date	:	04/06/2019
Last Update Date	:	04/06/2019

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Directions to “DIVINE PROVIDENCE INC ” Practice Location

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