Provider Demographics
NPI:1386920536
Name:DESTINY ROSE RESIDENTIAL CARE FACILITY
Entity type:Organization
Organization Name:DESTINY ROSE RESIDENTIAL CARE FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN-MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-778-7228
Mailing Address - Street 1:PO BOX 543174
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-3174
Mailing Address - Country:US
Mailing Address - Phone:214-778-7228
Mailing Address - Fax:214-377-5009
Practice Address - Street 1:1620 GLEN AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-1727
Practice Address - Country:US
Practice Address - Phone:214-335-0627
Practice Address - Fax:214-941-0308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-01
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00000000000000000000310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility