Organization
DIVINE HEALTH PRIMARY CARE CLINIC, LLC
Active
Other names
Divine Health and Primary Care Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
DR. OFUNDEM ROSE GWAN M.D. (OWNER/PHYSICIAN)
(318) 259-1204
Entity
Organization
Contact information
Practice address
1401 EZELL STREET, RUSTON, LA 71270-7218
(318) 259-1204
(318) 259-1255
Mailing address
1401 EZELL STREET, RUSTON, LA 71270-7218
(318) 259-1204
(318) 259-1255
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
203609
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1245440940
INDIVIDUAL NPI
LA
Enumeration date
04/25/2012
Last updated
04/25/2012
About Stedi
Stedi is the only programmable healthcare clearinghouse. You can use Stedi's APIs to process eligibility checks, claims, remits, and more.
Contact us