Healthcare Provider Details

I. General information

NPI: 1629419098
Provider Name (Legal Business Name): NEW DESTINATIONS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 MIRACLE LN
FAYETTEVILLE NC
28311-3216
US

IV. Provider business mailing address

5720 TURNER STORE LN
RALEIGH NC
27603-7976
US

V. Phone/Fax

Practice location:
  • Phone: 919-773-2706
  • Fax: 980-225-0385
Mailing address:
  • Phone: 919-773-2706
  • Fax: 980-225-0385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: MR. LARRY LEE LACKEY
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 919-773-2706