MEDICARE: DIVINE DIAGNOSTIC COMPANY

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	305S00000X	Point of Service

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0E03743	OTHER		BC
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881901668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE DIAGNOSTIC COMPANY

Provider Business Mailing Address
First Line	:	5005 E 14 MILE RD STE 100
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-6533
Country	:	US
Telephone Number	:	586-795-3815
Fax Number	:	586-620-6062

Provider Business Practice Location Address
First Line	:	5005 E 14 MILE RD STE 100
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-6533
Country	:	US
Telephone Number	:	586-795-3815
Fax Number	:	586-620-6062

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	MS. SUHA ALAKA
Credential	:
Telephone Number	:	586-713-8397

Provider Enumeration Date	:	09/01/2010
Last Update Date	:	08/15/2013

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Directions to “DIVINE DIAGNOSTIC COMPANY ” Practice Location

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