Healthcare Provider Details

I. General information

NPI: 1508795527
Provider Name (Legal Business Name): DIVINE VAGINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 CLOVER LN
RANDOLPH NJ
07869-4529
US

IV. Provider business mailing address

20 CLOVER LN
RANDOLPH NJ
07869-4529
US

V. Phone/Fax

Practice location:
  • Phone: 973-876-2509
  • Fax: 973-876-2509
Mailing address:
  • Phone: 973-876-2509
  • Fax: 973-876-2509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DARIA TAVANA
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: DPT
Phone: 973-876-2509