Provider Demographics
NPI:1699147116
Name:DIVINE AGING, LLC
Entity type:Organization
Organization Name:DIVINE AGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PARVINDER
Authorized Official - Middle Name:S
Authorized Official - Last Name:KAINTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-271-1984
Mailing Address - Street 1:2325 ULMERTON RD
Mailing Address - Street 2:SUITE 19
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33762-2282
Mailing Address - Country:US
Mailing Address - Phone:727-271-1984
Mailing Address - Fax:727-210-3036
Practice Address - Street 1:2325 ULMERTON RD
Practice Address - Street 2:SUITE 19
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762-2282
Practice Address - Country:US
Practice Address - Phone:727-271-1984
Practice Address - Fax:727-210-3036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-23
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL207R00000X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty