MEDICARE: DIVINEGRACE PRIMARY URGENT CARE IV HYDRATION & WELLNESS CLINIC 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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
2	363LF0000X	Family Nurse Practitioner

General Provider Information

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

Provider Business Mailing Address
First Line	:	12912 CROSSFIELD DR
Second Line	:
City	:	BELTSVILLE
State	:	MD
Zip	:	20705-6334
Country	:	US
Telephone Number	:	240-476-9409
Fax Number	:

Provider Business Practice Location Address
First Line	:	9420 ANNAPOLIS RD STE 103
Second Line	:
City	:	LANHAM
State	:	MD
Zip	:	20706-3033
Country	:	US
Telephone Number	:	240-476-9409
Fax Number	:	240-436-0043

Authorized Official
Title or Position	:	OWNER
Name	:	GRACE CHIKEZIE
Credential	:
Telephone Number	:	240-476-9409

Provider Enumeration Date	:	10/16/2023
Last Update Date	:	06/09/2026

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