Provider Demographics
NPI:1053659714
Name:DIVINE HEALTH CARE, LLC
Entity Type:Organization
Organization Name:DIVINE HEALTH CARE, LLC
Other - Org Name:DIVINE HEALTH CARE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:FOSTER
Authorized Official - Last Name:CHINNERY
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, FNP
Authorized Official - Phone:757-826-0514
Mailing Address - Street 1:2207 EXECUTIVE DR
Mailing Address - Street 2:STE B
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2478
Mailing Address - Country:US
Mailing Address - Phone:757-826-1600
Mailing Address - Fax:757-826-0160
Practice Address - Street 1:2207 EXECUTIVE DR
Practice Address - Street 2:STE B
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2478
Practice Address - Country:US
Practice Address - Phone:757-826-1600
Practice Address - Fax:757-826-0160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-30
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017000454261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care