DESTINATION LIFE LLC-S

Provider Demographics

• NPI: 1023625894
• Name: DESTINATION LIFE LLC-S
• Entity type: Organization
• Organization Name: DESTINATION LIFE LLC-S
• Other - Org Name: <UNAVAIL>
• Authorized Official - Title/Position: ADM
• Authorized Official - First Name: ZEMELDA
• Authorized Official - Middle Name: D
• Authorized Official - Last Name: CARR
• Authorized Official - Phone: 817-473-1312
• Mailing Address - Street 1: 2001 SE GREEN OAK BLVD STE 130
• Mailing Address - City: ARLINGTON
• Mailing Address - State: TX
• Mailing Address - Zip Code: 76018-0952
• Mailing Address - Country: US
• Mailing Address - Phone: 817-473-1312
• Mailing Address - Fax: 866-990-2813
• Practice Address - Street 1: 7 JONATHAN WAY
• Practice Address - City: ELLISVILLE
• Practice Address - State: MS
• Practice Address - Zip Code: 39437-5195
• Practice Address - Country: US
• Practice Address - Phone: 817-473-1312
• Practice Address - Fax: 866-990-2813
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2020-09-25
• Last Update Date: 2021-07-30

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	364SP0807X	Physician Assistants & Advanced Practice Nursing Providers	Clinical Nurse Specialist	Psychiatric/Mental Health, Child & Adolescent	Group - Multi-Specialty
No	1041C0700X	Behavioral Health & Social Service Providers	Social Worker	Clinical	Group - Multi-Specialty
No	163WP0807X	Nursing Service Providers	Registered Nurse	Psychiatric/Mental Health, Child & Adolescent	Group - Multi-Specialty
No	225X00000X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Occupational Therapist		Group - Multi-Specialty
No	225XM0800X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Occupational Therapist	Mental Health	Group - Multi-Specialty
No	261QP2300X	Ambulatory Health Care Facilities	Clinic/Center	Primary Care	Group - Multi-Specialty
No	261QR0401X	Ambulatory Health Care Facilities	Clinic/Center	Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)	Group - Multi-Specialty
No	291U00000X	Laboratories	Clinical Medical Laboratory		Group - Multi-Specialty
No	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty
No	363LC1500X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Community Health	Group - Multi-Specialty
No	363LF0000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Family	Group - Multi-Specialty
No	363LP0808X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Psychiatric/Mental Health	Group - Multi-Specialty
No	363LW0102X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Women's Health	Group - Multi-Specialty
No	364S00000X	Physician Assistants & Advanced Practice Nursing Providers	Clinical Nurse Specialist		Group - Multi-Specialty
No	364SP0808X	Physician Assistants & Advanced Practice Nursing Providers	Clinical Nurse Specialist	Psychiatric/Mental Health	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
MS	03320311	Medicaid
MS	25D2200016	Other	CLIA
TX	1C5803	Other	GROUP