Provider Demographics
NPI:1063734564
Name:DESTINY FAMILY CARE HOME
Entity type:Organization
Organization Name:DESTINY FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANTHONIA
Authorized Official - Middle Name:UZOAMAKA
Authorized Official - Last Name:EZUMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-345-4722
Mailing Address - Street 1:5005 HOLLYRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-3109
Mailing Address - Country:US
Mailing Address - Phone:919-789-9811
Mailing Address - Fax:919-789-9811
Practice Address - Street 1:5005 HOLLYRIDGE DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-3109
Practice Address - Country:US
Practice Address - Phone:919-789-9811
Practice Address - Fax:919-789-9811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-092-759320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities