Provider Demographics
NPI:1316426166
Name:DIVINE TRANSIT, LLC
Entity type:Organization
Organization Name:DIVINE TRANSIT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PHAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON-BURKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-405-2116
Mailing Address - Street 1:121 VINCA DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6533
Mailing Address - Country:US
Mailing Address - Phone:601-405-2116
Mailing Address - Fax:
Practice Address - Street 1:511 N BROAD ST
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-3511
Practice Address - Country:US
Practice Address - Phone:601-405-2116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)