Provider Demographics
NPI:1114101342
Name:DIVINE RESIDENTIAL SERVICES, LLC
Entity Type:Organization
Organization Name:DIVINE RESIDENTIAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMARA
Authorized Official - Middle Name:T
Authorized Official - Last Name:GRACIA
Authorized Official - Suffix:
Authorized Official - Credentials:QMHP
Authorized Official - Phone:804-306-1242
Mailing Address - Street 1:12501 CHESDIN LANDING DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23838-3230
Mailing Address - Country:US
Mailing Address - Phone:804-306-1242
Mailing Address - Fax:
Practice Address - Street 1:6206 MANUEL CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23234-5894
Practice Address - Country:US
Practice Address - Phone:804-918-1433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA89305001320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness