Healthcare Provider Details

I. General information

NPI: 1780466771
Provider Name (Legal Business Name): DIVINEGRACE PRIMARY URGENT CARE IV HYDRATION & WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9420 ANNAPOLIS RD STE 103
LANHAM MD
20706-3033
US

IV. Provider business mailing address

12912 CROSSFIELD DR
BELTSVILLE MD
20705-6334
US

V. Phone/Fax

Practice location:
  • Phone: 240-476-9409
  • Fax: 240-436-0043
Mailing address:
  • Phone: 240-476-9409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GRACE CHIKEZIE
Title or Position: OWNER
Credential:
Phone: 240-476-9409