Healthcare Provider Details

I. General information

NPI: 1821307620
Provider Name (Legal Business Name): LIFE & DESTINY BUILDERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19400 JOY RD
DETROIT MI
48228-3035
US

IV. Provider business mailing address

29460 STELLAMAR DR
SOUTHFIELD MI
48076-5272
US

V. Phone/Fax

Practice location:
  • Phone: 248-721-1526
  • Fax:
Mailing address:
  • Phone: 248-721-1526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DOREEN I BETHEL
Title or Position: /OWNER/CEO
Credential:
Phone: 248-721-1526