MEDICARE: GRACE DIVINE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner
2	363L00000X	Nurse Practitioner
3	363A00000X	Physician Assistant
4	208D00000X	General Practice Physician
5	207Q00000X	Family Medicine Physician	38836	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548596372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE DIVINE, LLC

Provider Business Mailing Address
First Line	:	8900 KEYSTONE XING STE 540
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-2130
Country	:	US
Telephone Number	:	317-429-0120
Fax Number	:	317-800-7730

Provider Business Practice Location Address
First Line	:	8900 KEYSTONE XING STE 540
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-2130
Country	:	US
Telephone Number	:	317-429-0120
Fax Number	:	317-800-7730

Authorized Official
Title or Position	:	CEO
Name	:	DR. RODNEY C ARMSTEAD
Credential	:	MD
Telephone Number	:	310-418-7250

Provider Enumeration Date	:	10/29/2009
Last Update Date	:	04/10/2026

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Directions to “GRACE DIVINE, LLC ” Practice Location

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