Provider Demographics
NPI:1114400157
Name:DIVINE SUPPORTS & HOMES INC.
Entity Type:Organization
Organization Name:DIVINE SUPPORTS & HOMES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAVIS
Authorized Official - Middle Name:NGUM
Authorized Official - Last Name:TAH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:240-413-7682
Mailing Address - Street 1:9716 ANITA LN
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3307
Mailing Address - Country:US
Mailing Address - Phone:240-413-7682
Mailing Address - Fax:
Practice Address - Street 1:13005 MAEPINE CT
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3130
Practice Address - Country:US
Practice Address - Phone:240-413-7682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities