Provider Demographics
NPI:1487786307
Name:DIVINE HEALTHCARE SUPPLIES, LLC
Entity type:Organization
Organization Name:DIVINE HEALTHCARE SUPPLIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALUMA
Authorized Official - Middle Name:K
Authorized Official - Last Name:ORUH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-967-2193
Mailing Address - Street 1:7380 SPOUT SPRINGS RD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-7541
Mailing Address - Country:US
Mailing Address - Phone:770-967-2193
Mailing Address - Fax:770-967-2199
Practice Address - Street 1:7380 SPOUT SPRINGS RD
Practice Address - Street 2:SUITE 190
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-7541
Practice Address - Country:US
Practice Address - Phone:770-967-2193
Practice Address - Fax:770-967-2199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABL07086332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6056590001Medicare NSC