Provider Demographics
NPI:1891449674
Name:DIVINE HEALTHCARE SERVICES LLC
Entity Type:Organization
Organization Name:DIVINE HEALTHCARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTUS
Authorized Official - Middle Name:
Authorized Official - Last Name:GICHABA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-371-2657
Mailing Address - Street 1:15320 WITS END DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-5889
Mailing Address - Country:US
Mailing Address - Phone:678-371-2657
Mailing Address - Fax:
Practice Address - Street 1:4343 DALE BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-2401
Practice Address - Country:US
Practice Address - Phone:678-371-2657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome HealthGroup - Multi-Specialty
No376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Multi-Specialty