Healthcare Provider Details

I. General information

NPI: 1588287163
Provider Name (Legal Business Name): DESTINATION LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SE GREEN OAKS BLVD STE 130
ARLINGTON TX
76018-0952
US

IV. Provider business mailing address

1759 BROAD PARK CIR S STE 113
MANSFIELD TX
76063-7836
US

V. Phone/Fax

Practice location:
  • Phone: 817-473-1312
  • Fax: 866-990-2813
Mailing address:
  • Phone: 817-473-1312
  • Fax: 866-990-2813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: ZEMELDA D. CARR
Title or Position: ADM & AUTH REP
Credential:
Phone: 817-473-1312