Healthcare Provider Details

I. General information

NPI: 1487364204
Provider Name (Legal Business Name): DESTIN SENIOR CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 MATTIE KELLY BLVD
DESTIN FL
32541-2811
US

IV. Provider business mailing address

421 N MACARTHUR AVE
PANAMA CITY FL
32401-3767
US

V. Phone/Fax

Practice location:
  • Phone: 317-514-5985
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: TAYLOR HUSTON
Title or Position: GENERAL COUNSEL
Credential: ESQ.
Phone: 317-514-5985