Provider Demographics
NPI:1972895043
Name:DESTINY TRANSPORTATION SVC
Entity type:Organization
Organization Name:DESTINY TRANSPORTATION SVC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-698-0052
Mailing Address - Street 1:1427 LEXINGTON PL
Mailing Address - Street 2:2R
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-2701
Mailing Address - Country:US
Mailing Address - Phone:908-414-1376
Mailing Address - Fax:908-235-4202
Practice Address - Street 1:51 JFK PARKWAY
Practice Address - Street 2:FIRST FLOOR WEST
Practice Address - City:SHORT HILLS
Practice Address - State:NJ
Practice Address - Zip Code:07078-5602
Practice Address - Country:US
Practice Address - Phone:973-218-2674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-09
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0400410271343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)