=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053543371
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DESTINY LIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2009
-----------------------------------------------------
Last Update Date | 08/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9230 N CYPRESS CIR
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33025-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-435-2882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9230 N CYPRESS CIR
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33025-2440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | GERALD OVIASOGIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-665-8740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL11567
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------