Organization
DIVERGENT SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. KENNIE NICOLE JACKSON WALCOTT (OWNER/CAREGIVER)
(317) 362-3792
Entity
Organization
Contact information
Practice address
3955 CAMPBELL AVE, INDIANAPOLIS, IN 46226-4836
(317) 362-3792
Mailing address
3955 CAMPBELL AVE, INDIANAPOLIS, IN 46226-4836
(317) 362-3792
Taxonomy
Speciality
Code
Description
License number
State
251V00000X
Voluntary or Charitable Agency
—
—
253Z00000X
In Home Supportive Care Agency
Primary
—
—
332U00000X
Home Delivered Meals
—
—
385H00000X
Respite Care
—
—
Other
Enumeration date
07/14/2010
Last updated
07/14/2010
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