Provider Demographics
NPI:1144047929
Name:DIVINE MERCY HEALTH CENTER
Entity type:Organization
Organization Name:DIVINE MERCY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILBUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-409-3019
Mailing Address - Street 1:6221 COLONEL GLENN RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-7731
Mailing Address - Country:US
Mailing Address - Phone:501-223-2776
Mailing Address - Fax:501-223-2779
Practice Address - Street 1:6221 COLONEL GLENN RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-7731
Practice Address - Country:US
Practice Address - Phone:501-223-2776
Practice Address - Fax:501-223-2779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty