1023625894 NPI number — DESTINATION LIFE LLC-S

Table of content: (NPI 1023625894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023625894 NPI number — DESTINATION LIFE LLC-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESTINATION LIFE LLC-S
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:
SAJOURNEY
Provider Other Organization Name Type Code:
3
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:
1023625894
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 SE GREEN OAK 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:
7 JONATHAN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLISVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39437-5195
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:
09/25/2020

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
Authorized Official Telephone Number:
817-473-1312

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WP0807X ; 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: 225XM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LW0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0807X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 364SP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 03320311 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 25D2200016 . This is a "CLIA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1C5803 . This is a "GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".