Provider Demographics
NPI:1710197785
Name:DIVINE INJURY CLINIC & REHAB, P.C.
Entity type:Organization
Organization Name:DIVINE INJURY CLINIC & REHAB, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:OGECHI
Authorized Official - Middle Name:
Authorized Official - Last Name:GUINNESS-OHAZURUIKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-279-0644
Mailing Address - Street 1:3220 GUS THOMASSON RD
Mailing Address - Street 2:SUITE 233
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4057
Mailing Address - Country:US
Mailing Address - Phone:972-279-0644
Mailing Address - Fax:972-279-0655
Practice Address - Street 1:3220 GUS THOMASSON RD
Practice Address - Street 2:SUITE 233
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4057
Practice Address - Country:US
Practice Address - Phone:972-279-0644
Practice Address - Fax:972-279-0655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10276111NR0400X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305S00000XManaged Care OrganizationsPoint of ServiceGroup - Single Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXV12254Medicare UPIN