Healthcare Provider Details

I. General information

NPI: 1457998551
Provider Name (Legal Business Name): NEW DESTINY HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2019
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 E DRAGON FLY RD
QUEEN CREEK AZ
85143
US

IV. Provider business mailing address

530 E HUNT HWY SUITE 103-188
SAN TAN VALLEY AZ
85143
US

V. Phone/Fax

Practice location:
  • Phone: 480-522-0566
  • Fax:
Mailing address:
  • Phone: 480-522-0566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFF BOLANOS
Title or Position: MEMBER-MANAGER
Credential: MD
Phone: 480-522-0566