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General NPI Number Information
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NPI Number | 1619793445
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Entity Type | Organization
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Legal Business Name | DIVINE RESIDENTIAL SERVICES, LLC
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Dates
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Enumeration Date | 11/26/2024
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Last Update Date | 01/02/2025
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Provider Practice Location Address
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Address Line | 2101 PROPER ST
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City | CORINTH
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State | MS
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Zip | 38834-5247
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Country | US
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Telephone | 225-810-0261
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Fax |
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Provider Business Mailing Address
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Address Line | 18519 LOCH BEND AVE
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City | GREENWELL SPRINGS
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State | LA
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Zip | 70739-4776
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. BRANDON LAVAR TRIGGS
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Credential | MBA
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Telephone | 225-810-0261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 323P00000X
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Taxonomy Name | Psychiatric Residential Treatment Facility
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License Number |
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License Number State |
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