1144554007 NPI number — DESTINY'S HOUSE INTENSIVE IN-HOME

Table of content: (NPI 1144554007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144554007 NPI number — DESTINY'S HOUSE INTENSIVE IN-HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESTINY'S HOUSE INTENSIVE IN-HOME
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:
1144554007
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6060 JEFFERSON AVE
Provider Second Line Business Mailing Address:
STE 9003
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23605-3014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6060 JEFFERSON AVE
Provider Second Line Business Practice Location Address:
STE 9003
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23605-3014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-706-3382
Provider Business Practice Location Address Fax Number:
757-706-3383
Provider Enumeration Date:
09/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MUHAMMAD
Authorized Official First Name:
PATRICE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
757-706-3382

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  990 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 990 . This is a "DMHMRSAS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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