=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114101342
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVINE RESIDENTIAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2007
-----------------------------------------------------
Last Update Date | 12/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6206 MANUEL CT
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23234-5894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-918-1433
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12501 CHESDIN LANDING DR
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23838-3230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-306-1242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. SAMARA T GRACIA
-----------------------------------------------------
Credential | QMHP
-----------------------------------------------------
Telephone | 804-306-1242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 89305001
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------