Provider Demographics
NPI:1154027860
Name:DREAMLIFE DESTINY LLC
Entity type:Organization
Organization Name:DREAMLIFE DESTINY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-226-3063
Mailing Address - Street 1:9488 KINGSVIEW LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-8571
Mailing Address - Country:US
Mailing Address - Phone:612-730-3436
Mailing Address - Fax:
Practice Address - Street 1:9488 KINGSVIEW LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-8571
Practice Address - Country:US
Practice Address - Phone:612-730-3436
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health