Healthcare Provider Details

I. General information

NPI: 1245371939
Provider Name (Legal Business Name): DESTINY HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 RIPPLING STREAM RD
DURHAM NC
27704-1233
US

IV. Provider business mailing address

1708 VINTAGE RD
RALEIGH NC
27610-3187
US

V. Phone/Fax

Practice location:
  • Phone: 919-454-7725
  • Fax: 919-231-3736
Mailing address:
  • Phone: 919-454-7725
  • Fax: 919-231-3736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMHL-032-389
License Number StateNC

VIII. Authorized Official

Name: OSWALD NWOGBO
Title or Position: DIRECTOR
Credential:
Phone: 919-454-7725