Provider Demographics
NPI:1548596372
Name:GRACE DIVINE, LLC
Entity type:Organization
Organization Name:GRACE DIVINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:ARMSTEAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-418-7250
Mailing Address - Street 1:PO BOX 503108
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-8108
Mailing Address - Country:US
Mailing Address - Phone:317-429-0120
Mailing Address - Fax:317-800-7730
Practice Address - Street 1:907 N EAST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3425
Practice Address - Country:US
Practice Address - Phone:317-429-0120
Practice Address - Fax:317-800-7730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-29
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38836207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty