MEDICARE: DIVERGENT SERVICES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251V00000X	Voluntary or Charitable Agency
2	332U00000X	Home Delivered Meals
3	385H00000X	Respite Care
4	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1821300245
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERGENT SERVICES

Provider Business Mailing Address
First Line	:	3955 CAMPBELL AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46226-4836
Country	:	US
Telephone Number	:	317-362-3792
Fax Number	:

Provider Business Practice Location Address
First Line	:	3955 CAMPBELL AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46226-4836
Country	:	US
Telephone Number	:	317-362-3792
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CAREGIVER
Name	:	MRS. KENNIE NICOLE JACKSON WALCOTT
Credential	:
Telephone Number	:	317-362-3792

Provider Enumeration Date	:	07/14/2010
Last Update Date	:	07/14/2010

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Directions to “DIVERGENT SERVICES ” Practice Location

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