# DIVINE HEALTH PRIMARY CARE CLINIC, LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Divine Health and Primary Care Clinic
- **Organization subpart:** No

## Provider details

- **NPI number:** 1548528854
- **Authorized official:** DR. OFUNDEM ROSE GWAN M.D. (OWNER/PHYSICIAN)
- **Authorized official phone:** (318) 259-1204

## Contact information

- **Practice address:** 1401 EZELL STREET, RUSTON, LA 71270-7218
- **Practice address phone:** (318) 259-1204
- **Practice address fax:** (318) 259-1255
- **Mailing address:** 1401 EZELL STREET, RUSTON, LA 71270-7218
- **Mailing address phone:** (318) 259-1204
- **Mailing address fax:** (318) 259-1255

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | 203609 | LA | Yes |

## Other

- **Enumeration date:** 04/25/2012
- **Last updated:** 04/25/2012