DIVINE HEALTH PRIMARY CARE CLINIC, LLC (NPI# 1548528854) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1548528854 |
| Entity Type | Organization |
| Organization Name | DIVINE HEALTH PRIMARY CARE CLINIC, LLC |
| Other Organization Name | DIVINE HEALTH AND PRIMARY CARE CLINIC |
| Practice Address |
1401 Ezell Street Ruston LA 71270-7218 |
| Practice Telephone | 3182591204 |
| Practice Fax Number | 3182591255 |
| Mailing Telephone | 3182591204 |
| Mailing Fax Number | 3182591255 |
| Enumeration Date | 2012-04-25 |
| Last Update Date | 2012-04-25 |
| Authorized Official Name | DR. OFUNDEM ROSE GWAN (OWNER/PHYSICIAN) |
| Authorized Official Telephone | 3182591204 |
| Authorized Official Credential | M.D. |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 207R00000X | Internal Medicine | 203609 | LA | Allopathic & Osteopathic Physicians |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| LA | INDIVIDUAL NPI | 1245440940 | 01 |
| Other Name | Type Code |
|---|---|
| Divine Health and Primary Care Clinic | Doing Business As Name - Organization |
| Street Address |
1401 EZELL STREET |
| City | RUSTON |
| State | LA |
| Zip Code | 71270-7218 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1720035645 | David Lanson Wheeler | Psychologist | 1401 Ezell Street, Ruston, LA 71270 | 2006-05-27 |
| 1871850735 | Ruston Pulmonary and Critical Care Specialist, L L C | Internal Medicine | 1401 Ezell Street, Ruston, LA 71270-7218 | 2012-04-17 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1144821315 | Olivia Mason | Marriage & Family Therapist | 413 North Homer Street, Ruston, LA 71270 | 2020-11-04 |
| 1972146132 | Razz Addiction and Recovery, LLC | Family Medicine | 570 Heard Rd, Ruston, LA 71270 | 2019-10-21 |
| 1518435999 | Tenia Holloway | Case Manager/Care Coordinator | 612 Henderson St., F12, Ruston, LA 71270 | 2018-11-05 |
| 1245708718 | A Plus Medical of Ruston LLC | Family Medicine | 612 S Farmerville Street, Ruston, LA 71270 | 2018-11-02 |
| 1255808085 | Amanda M Clark | Specialist/Technologist | 2301 Timberline Ct Apt F105, Ruston, LA 71270 | 2018-10-30 |
| 1912473752 | Lincoln Nova Vital Recovery | Counselor | 4396 Hwy, 80, 617 South Trention, Ruston, LA 71270 | 2018-10-19 |
| 1861975237 | Wymeka Andrea Breaux | Case Manager/Care Coordinator | 705 Martin Luther King Dr., Ruston, LA 71270 | 2018-09-12 |
| 1790292001 | Louquyhanta Foster | Case Manager/Care Coordinator | 593 Belton Rd, Ruston, LA 71270 | 2018-01-08 |
| 1609391010 | Chemia Herron | Counselor | 775 S Bonner, Ruston, LA 71270 | 2017-08-07 |
| 1477083517 | Arnesha Beard | Counselor | 775 South Bonner, Ruston, LA 71270 | 2017-06-12 |
| Find all providers in zip 71270 | ||||
| Taxonomy Code | 207R00000X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Internal Medicine |
| A physician who provides long-term, comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults and the elderly. Internists are trained in the diagnosis and treatment of cancer, infections and diseases affecting the heart, blood, kidneys, joints and digestive, respiratory and vascular systems. They are also trained in the essentials of primary care internal medicine, which incorporates an understanding of disease prevention, wellness, substance abuse, mental health and effective treatment of common problems of the eyes, ears, skin, nervous system and reproductive organs. |
| Notes: Source: American Board of Medical Specialties, 2007. www.abms.org [7/1/2007: added definition, added source; 7/1/2011: modified source] - Additional Resources: American Board of Internal Medicine, 2007. http://www.abim.org/. American Osteopathic Board of Internal Medicine, 2007. http://www.osteopathic.org/certification - Board certification for Medical Doctors (MDs) is provided by the American Board of Internal Medicine. Board certification for Doctors of Osteopathy (DOs) is provided by the American Osteopathic Board of Internal Medicine. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1477178804 | Enclave Health Plus LLC | Internal Medicine | 327 Jefferson Oaks Dr, Ruston, LA 71270-7080 | 2020-06-11 |
| 1245440940 | Ofundem Rose Gwan | Internal Medicine | 1406 S Vienna St, Ruston, LA 71270-6428 | 2007-05-23 |
| 1396770566 | Martina Abena Tamakloe | Internal Medicine | 1200 South Farmerville Street, Ruston, LA 71270 | 2006-07-12 |
| 1942786538 | Ssdn Saharans, Inc | Internal Medicine | 1401 Ezelle St, Ruston, LA 71270-7218 | 2018-07-17 |
| 1467647396 | Glenn Figueroa Md Apmc | Internal Medicine | 411 E Vaughn Ave, Suite 101, Ruston, LA 71270-5972 | 2007-09-13 |
| 1750575890 | Rochelle Robicheaux Metoyer | Internal Medicine | 1200 S Farmerville St, Ruston, LA 71270-5941 | 2007-08-31 |
| 1386652006 | Sedo Tamakloe | Internal Medicine | 1200 S Farmerville St, Ruston, LA 71270-5941 | 2006-08-05 |
| 1336108877 | Elvin Gregory Tubre | Internal Medicine | 1200 S Farmerville St, Ruston, LA 71270-5941 | 2006-03-22 |
| 1376513788 | Holly Kidd | Internal Medicine | 1200 S Farmerville St, Ruston, LA 71270-5941 | 2006-01-26 |
| 1467422824 | James V Jones | Internal Medicine | 1200 S Farmerville St, Ruston, LA 71270-5941 | 2006-01-26 |
| Find all providers in RUSTON | ||||
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.