Provider Demographics
NPI:1962164269
Name:DIVINE DERMATOLOGY AND SURGICAL INSTITUTE, PLLC
Entity type:Organization
Organization Name:DIVINE DERMATOLOGY AND SURGICAL INSTITUTE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:DIVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-286-2668
Mailing Address - Street 1:1260 DOCTORS LN STE A
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4072
Mailing Address - Country:US
Mailing Address - Phone:970-286-2668
Mailing Address - Fax:970-294-4954
Practice Address - Street 1:1715 IRON HORSE DR STE 104
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-9756
Practice Address - Country:US
Practice Address - Phone:970-286-2668
Practice Address - Fax:970-294-4954
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVINE DERMATOLOGY AND SURGICAL INSTITUE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty