MEDICARE: LIFE & DESTINY BUILDERS

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	261QC1500X	Community Health Clinic/Center
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1821307620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE & DESTINY BUILDERS

Provider Business Mailing Address
First Line	:	29460 STELLAMAR DR
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-5272
Country	:	US
Telephone Number	:	248-721-1526
Fax Number	:

Provider Business Practice Location Address
First Line	:	19400 JOY RD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48228-3035
Country	:	US
Telephone Number	:	248-721-1526
Fax Number	:

Authorized Official
Title or Position	:	/OWNER/CEO
Name	:	DOREEN I BETHEL
Credential	:
Telephone Number	:	248-721-1526

Provider Enumeration Date	:	09/28/2010
Last Update Date	:	09/28/2010

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Directions to “LIFE & DESTINY BUILDERS ” Practice Location

Language	Start Address	Practice Location

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