Healthcare Provider Details

I. General information

NPI: 1033558796
Provider Name (Legal Business Name): DESTINY BY THE SEA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2013
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 SE 14TH AVE
BOYNTON BEACH FL
33435-6030
US

IV. Provider business mailing address

130 SE 14TH AVE
BOYNTON BEACH FL
33435-6030
US

V. Phone/Fax

Practice location:
  • Phone: 561-350-3888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: ANGELA IACULLO
Title or Position: BILLING DIRECTOR
Credential:
Phone: 561-715-9288