Provider Demographics
NPI:1316304959
Name:DESTINATION INDEPENDENCE LLC
Entity type:Organization
Organization Name:DESTINATION INDEPENDENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEITER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-899-1920
Mailing Address - Street 1:103 BILTMORE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-2260
Mailing Address - Country:US
Mailing Address - Phone:210-899-1920
Mailing Address - Fax:210-444-9556
Practice Address - Street 1:103 BILTMORE ST STE 100
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78213-2260
Practice Address - Country:US
Practice Address - Phone:210-899-1920
Practice Address - Fax:210-444-9556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-27
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management