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General NPI Number Information
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NPI Number | 1548596372
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Entity Type | Organization
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Legal Business Name | GRACE DIVINE, LLC
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Dates
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Enumeration Date | 10/29/2009
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Last Update Date | 08/01/2024
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Provider Practice Location Address
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Address Line | 907 N EAST ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46202-3425
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Country | US
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Telephone | 317-429-0120
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Fax | 317-800-7730
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Provider Business Mailing Address
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Address Line | PO BOX 503108
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City | INDIANAPOLIS
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State | IN
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Zip | 46250-8108
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Country | US
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Telephone | 317-429-0120
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Fax | 317-800-7730
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Authorized Official
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Title or Position | CEO
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Name | RODNEY C ARMSTEAD
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Credential | MD
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Telephone | 310-418-7250
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QG0300X
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Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
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License Number | 38836
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License Number State | KY
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