MEDICARE: DESTINATION LIFE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	363L00000X	Nurse Practitioner
3	104100000X	Social Worker
4	207KI0005X	Clinical & Laboratory Immunology (Allergy & Immunology) Physician
5	251B00000X	Case Management Agency
6	251J00000X	Nursing Care Agency
7	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
8	261QM0850X	Adult Mental Health Clinic/Center
9	363LA2200X	Adult Health Nurse Practitioner
10	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
11	363LP2300X	Primary Care Nurse Practitioner
12	363LW0102X	Women's Health Nurse Practitioner
13	364SP0807X	Child & Adolescent Psychiatric/Mental Health Clinical Nurse Specialist
14	364SP0809X	Adult Psychiatric/Mental Health Clinical Nurse Specialist
15	225X00000X	Occupational Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	25D2200016	OTHER	MS	CLIA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629691167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTINATION LIFE LLC

Provider Business Mailing Address
First Line	:	2001 SE GREEN OAKS BLVD STE 130
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76018-0952
Country	:	US
Telephone Number	:	817-473-1312
Fax Number	:	866-990-2813

Provider Business Practice Location Address
First Line	:	2001 SE GREEN OAKS BLVD STE 130
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76018-0952
Country	:	US
Telephone Number	:	817-473-1312
Fax Number	:	866-990-2813

Authorized Official
Title or Position	:	ADM & AUTH REP
Name	:	ZEMELDA D. CARR
Credential	:
Telephone Number	:	817-473-1312

Provider Enumeration Date	:	05/19/2020
Last Update Date	:	03/16/2022

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