| Divine Health Medical And Spa Llc | |
|
11119 Rockville Pike Ste 320 Rockville MD 20852-3143 | |
| (240) 669-6598 | |
| (240) 669-6079 |
| Full Name | Divine Health Medical And Spa Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 11119 Rockville Pike Ste 320, Rockville, Maryland |
| Authorized Official Name and Position | Sally Owie Young (EDUCATOR) |
| Authorized Official Contact | 2404379997 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Divine Health Medical And Spa Llc 12406 Buckley Dr Silver Spring MD 20904-2017 Ph: (240) 437-9997 | Divine Health Medical And Spa Llc 11119 Rockville Pike Ste 320 Rockville MD 20852-3143 Ph: (240) 669-6598 |
| NPI Number | 1790428555 |
|---|---|
| Provider Enumeration Date | 04/19/2022 |
| Last Update Date | 07/14/2022 |
| Medicare PECOS PAC ID | 9739560574 |
|---|---|
| Medicare Enrollment ID | O20220725003095 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1790428555 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
| 363LF0000X | Nurse Practitioner - Family | (* (Not Available)) | Secondary |
| Provider Name | Sally O Young |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1568015634 PECOS PAC ID: 9638508914 Enrollment ID: I20200408000721 |
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