MEDICARE: DYVINE ELEVATION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1467323048
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYVINE ELEVATION, LLC

Provider Business Mailing Address
First Line	:	4707 PARVATHI CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4465
Country	:	US
Telephone Number	:	757-652-3310
Fax Number	:

Provider Business Practice Location Address
First Line	:	4707 PARVATHI CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4465
Country	:	US
Telephone Number	:	757-652-3310
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LUCRETIA ETHERIDGE
Credential	:
Telephone Number	:	757-652-3310

Provider Enumeration Date	:	09/16/2025
Last Update Date	:	09/16/2025

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Directions to “DYVINE ELEVATION, LLC ” Practice Location

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