Healthcare Provider Details

I. General information

NPI: 1093037566
Provider Name (Legal Business Name): DESTINED REVISIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2010
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

947 BRYANT HILL RD
MARSHALLVILLE GA
31057-3113
US

IV. Provider business mailing address

2550 E WESLEY CHAPEL WAY STE 5
DECATUR GA
30035-3430
US

V. Phone/Fax

Practice location:
  • Phone: 678-468-4880
  • Fax:
Mailing address:
  • Phone: 678-468-4880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateGA

VIII. Authorized Official

Name: MISS JOY JUNESE GRIER
Title or Position: OWNER
Credential: B.S
Phone: 678-468-4880