Organization
DIVINE RESIDENTIAL SERVICES, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. SAMARA T GRACIA QMHP (EXECUTIVE DIRECTOR)
(804) 306-1242
Entity
Organization
Contact information
Practice address
6206 MANUEL CT, RICHMOND, VA 23234-5894
(804) 918-1433
Mailing address
12501 CHESDIN LANDING DR, CHESTERFIELD, VA 23838-3230
(804) 306-1242
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
Primary
89305001
VA
Other
Enumeration date
12/24/2007
Last updated
12/24/2007
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