Provider Demographics
NPI:1578324141
Name:DIVINE INNOVATION SERVICES LLC
Entity Type:Organization
Organization Name:DIVINE INNOVATION SERVICES LLC
Other - Org Name:DIVINE INNOVATION SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:LANAE
Authorized Official - Last Name:PEARSALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-675-8937
Mailing Address - Street 1:12400 WAKE UNION CHURCH RD # 3-256
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-4509
Mailing Address - Country:US
Mailing Address - Phone:919-675-8937
Mailing Address - Fax:
Practice Address - Street 1:120 CAPCOM AVE STE 102B
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6537
Practice Address - Country:US
Practice Address - Phone:919-675-8937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-19
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No385H00000XRespite Care FacilityRespite Care
No385HR2050XRespite Care FacilityRespite CareRespite Care Camp
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child