Provider Demographics
NPI:1114328416
Name:DESTINATION LIFE LLC
Entity type:Organization
Organization Name:DESTINATION LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM AND AUTH REP
Authorized Official - Prefix:
Authorized Official - First Name:ZEMELDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-473-1312
Mailing Address - Street 1:2001 SE GREEN OAKS BLVD STE 130
Mailing Address - Street 2:
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 1:2001 SE GREEN OAKS BLVD STE 130
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-0952
Practice Address - Country:US
Practice Address - Phone:817-473-1312
Practice Address - Fax:866-990-2813
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESTINATION LIFE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163W00000X, 224Z00000X, 225X00000X, 253Z00000X, 305S00000X, 314000000X, 332B00000X, 3747P1801X, 374U00000X, 251E00000X, 251E00000X, 332BN1400X, 363L00000X, 261QR0400X
TX251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Multi-Specialty
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing FacilityGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility SuppliesGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1114328416OtherNIP
TX567960000OtherFACILITY LICENSE
TX404951202Medicaid
TX482228OtherMEDICARE PTAN
TX324611YS3BOtherGROUP MEDICARE
TX4049512Medicaid
TX365911201Medicaid
TX567960000OtherLICENSE
TX7760000001OtherDME
TX365911202Medicaid