Provider Demographics
NPI:1124262712
Name:DIVINE HOUSE, LLC
Entity type:Organization
Organization Name:DIVINE HOUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BELA
Authorized Official - Middle Name:SV
Authorized Official - Last Name:AMIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:757-202-0825
Mailing Address - Street 1:912 BEAUMEADE CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-4642
Mailing Address - Country:US
Mailing Address - Phone:757-202-0825
Mailing Address - Fax:
Practice Address - Street 1:3429 STIRRUP WAY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23453-8546
Practice Address - Country:US
Practice Address - Phone:757-202-0825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1157320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities