Healthcare Provider Details

I. General information

NPI: 1114693603
Provider Name (Legal Business Name): PRESERVERS OF DESTINIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 E VINE ST
KISSIMMEE FL
34744-3730
US

IV. Provider business mailing address

1621 E VINE ST
KISSIMMEE FL
34744-3730
US

V. Phone/Fax

Practice location:
  • Phone: 407-847-4152
  • Fax:
Mailing address:
  • Phone: 407-847-4152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MARISOL LUGO
Title or Position: CEO
Credential:
Phone: 407-847-4152