Healthcare Provider Details

I. General information

NPI: 1962325472
Provider Name (Legal Business Name): DESTINY MED SPA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5636 NW 167TH ST
MIAMI LAKES FL
33014-6135
US

IV. Provider business mailing address

5636 NW 167TH ST
MIAMI LAKES FL
33014-6135
US

V. Phone/Fax

Practice location:
  • Phone: 305-800-5476
  • Fax:
Mailing address:
  • Phone: 305-800-5476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: EDNA VIVIANA AYALA
Title or Position: OWNER
Credential:
Phone: 786-444-6589