Provider Demographics
NPI:1619793445
Name:DIVINE RESIDENTIAL SERVICES, LLC
Entity type:Organization
Organization Name:DIVINE RESIDENTIAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:LAVAR
Authorized Official - Last Name:TRIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:225-810-0261
Mailing Address - Street 1:18519 LOCH BEND AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWELL SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70739-4776
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2101 PROPER ST
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-5247
Practice Address - Country:US
Practice Address - Phone:225-810-0261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-26
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility