| Divine Health And Primary Care Clinic | |
|
1401 Ezell Street Ruston LA 71270-7218 | |
| (318) 259-1204 | |
| (318) 259-1255 |
| Full Name | Divine Health And Primary Care Clinic |
|---|---|
| Speciality | Internal Medicine |
| Location | 1401 Ezell Street, Ruston, Louisiana |
| Authorized Official Name and Position | Ofundem Rose Gwan (OWNER/PHYSICIAN) |
| Authorized Official Contact | 3182591204 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Divine Health And Primary Care Clinic 1401 Ezell Street Ruston LA 71270-7218 Ph: (318) 259-1204 | Divine Health And Primary Care Clinic 1401 Ezell Street Ruston LA 71270-7218 Ph: (318) 259-1204 |
| NPI Number | 1548528854 |
|---|---|
| Provider Enumeration Date | 04/25/2012 |
| Last Update Date | 04/25/2012 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1548528854 | NPI | - | NPPES |
| 1245440940 | Other | LA | INDIVIDUAL NPI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | 203609 (Louisiana) | Primary |
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