Provider Demographics
NPI:1194901736
Name:DIVINE MEDICAL OUTREACH SERVICES
Entity type:Organization
Organization Name:DIVINE MEDICAL OUTREACH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE/CASEMGR.
Authorized Official - Prefix:MRS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:GOLDSBY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:501-516-2322
Mailing Address - Street 1:5553 SPRINGVALE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-3740
Mailing Address - Country:US
Mailing Address - Phone:501-516-2322
Mailing Address - Fax:501-771-9211
Practice Address - Street 1:5553 SPRINGVALE RD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-3740
Practice Address - Country:US
Practice Address - Phone:501-516-2322
Practice Address - Fax:501-771-9211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR66896261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service