Provider Demographics
NPI:1548528854
Name:DIVINE HEALTH PRIMARY CARE CLINIC, LLC
Entity type:Organization
Organization Name:DIVINE HEALTH PRIMARY CARE CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:OFUNDEM
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:GWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-259-1204
Mailing Address - Street 1:1401 EZELL STREET
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-7218
Mailing Address - Country:US
Mailing Address - Phone:318-259-1204
Mailing Address - Fax:318-259-1255
Practice Address - Street 1:1401 EZELL STREET
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-7218
Practice Address - Country:US
Practice Address - Phone:318-259-1204
Practice Address - Fax:318-259-1255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203609207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1245440940OtherINDIVIDUAL NPI