Provider Demographics
NPI:1578324141
Name:DIVINE INNOVATION SERVICES LLC
Entity type:Organization
Organization Name:DIVINE INNOVATION SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
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