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General NPI Number Information
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NPI Number | 1750614111
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Entity Type | Organization
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Legal Business Name | DIVINELY DIRECTED SERVICES
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Dates
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Enumeration Date | 09/16/2009
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Last Update Date | 09/16/2009
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Provider Practice Location Address
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Address Line | 2909 ARCADIA AVE
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City | PORTSMOUTH
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State | VA
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Zip | 23704-6055
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Country | US
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Telephone | 757-397-9058
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Fax | 757-558-6915
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Provider Business Mailing Address
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Address Line | 961 CANAL DR SUITE B
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City | CHESAPEAKE
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State | VA
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Zip | 23323-4766
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Country | US
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Telephone | 757-558-6914
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Fax | 757-558-6915
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Authorized Official
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Title or Position | CHIEF ADMINISTRATIVE OFFICER
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Name | DR. RODERICK S. HAWTHORNE SR.
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Credential | DMIN
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Telephone | 757-558-6914
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 1075-14-001
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License Number State | VA
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