MEDICARE: DIVINE HEALTHCARE SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	364SH0200X	Home Health Clinical Nurse Specialist
2	376G00000X	Nursing Home Administrator
3	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1891449674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE HEALTHCARE SERVICES LLC

Provider Business Mailing Address
First Line	:	15320 WITS END DR
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-5889
Country	:	US
Telephone Number	:	678-371-2657
Fax Number	:

Provider Business Practice Location Address
First Line	:	4343 DALE BLVD
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22193-2401
Country	:	US
Telephone Number	:	678-371-2657
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JUSTUS GICHABA
Credential	:
Telephone Number	:	678-371-2657

Provider Enumeration Date	:	02/09/2022
Last Update Date	:	02/09/2022

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