MEDICARE: DESTINY RESIDENTIAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1578412409
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTINY RESIDENTIAL LLC

Provider Business Mailing Address
First Line	:	4030 CANNING ST
Second Line	:
City	:	DANVILLE
State	:	IN
Zip	:	46122-6009
Country	:	US
Telephone Number	:	904-731-6454
Fax Number	:

Provider Business Practice Location Address
First Line	:	4030 CANNING ST
Second Line	:
City	:	DANVILLE
State	:	IN
Zip	:	46122-6009
Country	:	US
Telephone Number	:	904-731-6454
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MR. JUSTIN NDIZEYE
Credential	:
Telephone Number	:	904-731-6454

Provider Enumeration Date	:	01/23/2026
Last Update Date	:	01/23/2026

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