MEDICARE: DIVINE HEALTH AND WELLNESS

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	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1891251245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE HEALTH AND WELLNESS

Provider Business Mailing Address
First Line	:	2045 DUTCHESS RD
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-2312
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2045 DUTCHESS RD
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-2312
Country	:	US
Telephone Number	:	770-356-9703
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TABITHA MACON
Credential	:
Telephone Number	:	770-356-9703

Provider Enumeration Date	:	02/11/2019
Last Update Date	:	06/18/2020

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Directions to “DIVINE HEALTH AND WELLNESS ” Practice Location

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