Healthcare Provider Details

I. General information

NPI: 1952793101
Provider Name (Legal Business Name): PRESERVERS OF DESTINIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
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: 407-429-1144
  • Fax:
Mailing address:
  • Phone: 407-847-4152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MARISOL LUGO
Title or Position: PRESIDENT
Credential:
Phone: 407-429-1144