Provider Demographics
NPI:1265262398
Name:DIVINE SOURCE CARE, LLC
Entity type:Organization
Organization Name:DIVINE SOURCE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE
Authorized Official - Prefix:
Authorized Official - First Name:SYDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-499-2757
Mailing Address - Street 1:1547 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-1840
Mailing Address - Country:US
Mailing Address - Phone:800-337-4491
Mailing Address - Fax:
Practice Address - Street 1:1547 W OAK ST
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-1840
Practice Address - Country:US
Practice Address - Phone:800-337-4491
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-05
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)Group - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty