Provider Demographics
NPI:1255053864
Name:DYVINE CARE, LLC
Entity type:Organization
Organization Name:DYVINE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-309-2785
Mailing Address - Street 1:5305 CLEARWATER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-1445
Mailing Address - Country:US
Mailing Address - Phone:646-309-2785
Mailing Address - Fax:
Practice Address - Street 1:5305 CLEARWATER LAKE RD
Practice Address - Street 2:
Practice Address - City:MT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-1445
Practice Address - Country:US
Practice Address - Phone:646-309-2785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-12
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities