Healthcare Provider Details

I. General information

NPI: 1295965473
Provider Name (Legal Business Name): DESTINY HOME, INC. #2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 07/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 VINTAGE RD
RALEIGH NC
27610-3187
US

IV. Provider business mailing address

234 SEVEN OAKS RD
DURHAM NC
27704-1125
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 Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberMHL-032-487
License Number StateNC

VIII. Authorized Official

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