Provider Demographics
NPI:1124873906
Name:DIVINE DEZIRES
Entity type:Organization
Organization Name:DIVINE DEZIRES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRANIAL PROSTHESIS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TURQUISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-450-9309
Mailing Address - Street 1:9341 FOREST HILL BLVD
Mailing Address - Street 2:STE 650
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414
Mailing Address - Country:US
Mailing Address - Phone:305-450-9309
Mailing Address - Fax:
Practice Address - Street 1:9341 FOREST HILL BLVD
Practice Address - Street 2:STE 650
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:305-450-9309
Practice Address - Fax:561-484-1868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-23
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier