Healthcare Provider Details

I. General information

NPI: 1821794454
Provider Name (Legal Business Name): NEW DESTINY HEALING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 09/06/2026
Certification Date: 09/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 W HALF MOON CIR
SAN TAN VALLEY AZ
85142-4461
US

IV. Provider business mailing address

530 E HUNT HWY STE 103-188
SAN TAN VALLEY AZ
85143-6581
US

V. Phone/Fax

Practice location:
  • Phone: 626-710-2595
  • Fax:
Mailing address:
  • Phone: 626-710-2595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: JERRY BOLANOS
Title or Position: MEMBER
Credential:
Phone: 626-710-2595