Provider Demographics
NPI:1275348526
Name:DIVINE MEDICAL CENTER, INC
Entity type:Organization
Organization Name:DIVINE MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GELYS
Authorized Official - Middle Name:
Authorized Official - Last Name:GONGORA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:813-810-8650
Mailing Address - Street 1:6107 MEMORIAL HWY STE B
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-4564
Mailing Address - Country:US
Mailing Address - Phone:813-810-8650
Mailing Address - Fax:
Practice Address - Street 1:6107 MEMORIAL HWY STE B
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-4564
Practice Address - Country:US
Practice Address - Phone:813-810-8650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center