Provider Demographics
NPI:1194175745
Name:DIVINE HEALTH AND WELLNESS CORP
Entity type:Organization
Organization Name:DIVINE HEALTH AND WELLNESS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ADESUWA
Authorized Official - Middle Name:
Authorized Official - Last Name:OSAZUWA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-236-7529
Mailing Address - Street 1:6136 WARM RIVER RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-1757
Mailing Address - Country:US
Mailing Address - Phone:702-236-7529
Mailing Address - Fax:
Practice Address - Street 1:6136 WARM RIVER RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-1757
Practice Address - Country:US
Practice Address - Phone:702-236-7529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV103K00000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health