Provider Demographics
NPI:1154557825
Name:DESTINY MEDICAL SUPPLY
Entity type:Organization
Organization Name:DESTINY MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ENOBONG
Authorized Official - Middle Name:
Authorized Official - Last Name:PETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-452-0808
Mailing Address - Street 1:3300 S JONES BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-6787
Mailing Address - Country:US
Mailing Address - Phone:702-452-0808
Mailing Address - Fax:
Practice Address - Street 1:3300 S JONES BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6787
Practice Address - Country:US
Practice Address - Phone:702-452-0808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVMP00590332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies