Provider Demographics
NPI:1104150556
Name:DIVINE FOOTCARE CENTER INC
Entity type:Organization
Organization Name:DIVINE FOOTCARE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CELESTINA
Authorized Official - Middle Name:N
Authorized Official - Last Name:DURU
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:972-790-2800
Mailing Address - Street 1:2000 ESTERS RD STE 104
Mailing Address - Street 2:SUITE 104
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-9580
Mailing Address - Country:US
Mailing Address - Phone:972-790-2800
Mailing Address - Fax:972-790-2803
Practice Address - Street 1:2000 ESTERS RD STE 104
Practice Address - Street 2:SUITE 104
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-9580
Practice Address - Country:US
Practice Address - Phone:972-790-2800
Practice Address - Fax:972-790-2803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1903213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6355630001Medicare NSC