Healthcare Provider Details

I. General information

NPI: 1891628004
Provider Name (Legal Business Name): DIVINE GRACE LIMITED LIABILITY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2026
Last Update Date: 06/06/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16701 MELFORD BLVD STE 400
BOWIE MD
20715-4411
US

IV. Provider business mailing address

16701 MELFORD BLVD STE 400
BOWIE MD
20715-4411
US

V. Phone/Fax

Practice location:
  • Phone: 443-608-7077
  • Fax:
Mailing address:
  • Phone: 443-608-7077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name: MS. BUKOLA ADEBAYO
Title or Position: MANAGING DIRECTOR
Credential: MD
Phone: 443-608-7077