1114328416 NPI number — DESTINATION LIFE LLC

Table of content: (NPI 1114328416)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114328416 NPI number — DESTINATION LIFE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESTINATION LIFE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114328416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 SE GREEN OAKS BLVD STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76018-0952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-473-1312
Provider Business Mailing Address Fax Number:
866-990-2813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2001 SE GREEN OAKS BLVD STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76018-0952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-473-1312
Provider Business Practice Location Address Fax Number:
866-990-2813
Provider Enumeration Date:
09/06/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CARR
Authorized Official First Name:
ZEMELDA
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
ADM AND AUTH REP
Authorized Official Telephone Number:
817-473-1312

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 305S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3747P1801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 374U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1114328416 . This is a "NIP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 567960000 . This is a "FACILITY LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 404951202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 482228 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 324611YS3B . This is a "GROUP MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 4049512 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 365911201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 567960000 . This is a "LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 7760000001 . This is a "DME" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 365911202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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