Provider Demographics
NPI:1588287163
Name:DESTINATION LIFE LLC
Entity type:Organization
Organization Name:DESTINATION LIFE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADM & 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 1:1759 BROAD PARK CIR S STE 113
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-7836
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:2020-05-18
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7760000001OtherDME