NPIMap

Organization Active NPI

Divine Dermatology and Surgical Institute, PLLC

  • Dermatology Physician
  • Longmont, CO
National Provider Identifier
1962164269
Registry record updated Oct 13, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
DIVINE DERMATOLOGY AND SURGICAL INSTITUTE, PLLC
Practice address
1715 Iron Horse Dr Ste 104
Longmont, CO 80501-9756
Phone
(970) 286-2668
Fax
(970) 294-4954
NPI assigned
Oct 13, 2021
Last updated
Oct 13, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
DIVINE DERMATOLOGY AND SURGICAL INSTITUE, PLLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 13, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jennifer Michelle DivineNPI 1063779072
Title
Owner
Phone
(970) 286-2668

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology Physician 207N00000X Primary

Addresses

Primary practice location

1715 Iron Horse Dr Ste 104
Longmont, CO 80501-9756

Mailing address

1260 Doctors LN Ste a
Fort Collins, CO 80524-4072
Phone (970) 286-2668

Other names 1

  • Divine Dermatology Other name

National Provider Directory

National Provider Directory
Tax ID family
Divine Dermatology and Surgical Institute PLLC2 organizations share this tax ID, including this one
Part of
Divine Dermatology and Surgical Institute PLLC

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1715 Iron Horse Dr
Ste 104
Longmont, CO 80501
Phone (970) 286-2668

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1634083200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1634083200000",
    "number": "1962164269",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1260 DOCTORS LN STE A",
            "city": "FORT COLLINS",
            "state": "CO",
            "postal_code": "805244072",
            "telephone_number": "970-286-2668",
            "fax_number": "970-294-4954"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1715 IRON HORSE DR STE 104",
            "city": "LONGMONT",
            "state": "CO",
            "postal_code": "805019756",
            "telephone_number": "970-286-2668",
            "fax_number": "970-294-4954"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DIVINE DERMATOLOGY AND SURGICAL INSTITUTE, PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DIVINE DERMATOLOGY AND SURGICAL INSTITUE, PLLC",
        "enumeration_date": "2021-10-13",
        "last_updated": "2021-10-13",
        "certification_date": "2021-10-13",
        "status": "A",
        "authorized_official_last_name": "DIVINE",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "MICHELLE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "970-286-2668"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Divine Dermatology",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Longmont, CO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 13, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.