Provider Demographics
NPI:1376398479
Name:DIVON GROUP HOME FOR YOUNG ADULTS
Entity type:Organization
Organization Name:DIVON GROUP HOME FOR YOUNG ADULTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAKAHYA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERETT-GATLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-965-0739
Mailing Address - Street 1:4324 VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-4922
Mailing Address - Country:US
Mailing Address - Phone:703-965-0739
Mailing Address - Fax:
Practice Address - Street 1:4324 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-4922
Practice Address - Country:US
Practice Address - Phone:703-965-0739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-22
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care