Healthcare Provider Details

I. General information

NPI: 1790608610
Provider Name (Legal Business Name): DIVINELY CHAOTIC WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4169 VIRGINIA BEACH BLVD STE 109
VIRGINIA BEACH VA
23452-1761
US

IV. Provider business mailing address

3600 KINGDOM CT
VIRGINIA BEACH VA
23452-3202
US

V. Phone/Fax

Practice location:
  • Phone: 757-689-7802
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: TIFFANY CARTER
Title or Position: OWNER/ MASSAGE THERAPIST
Credential:
Phone: 757-389-2544