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General NPI Number Information
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NPI Number | 1083963607
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Entity Type | Organization
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Legal Business Name | DESTINY ADULT HOME DAY CARE
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Dates
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Enumeration Date | 08/29/2012
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Last Update Date | 08/29/2012
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Provider Practice Location Address
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Address Line | 3363 PINEGATE TRL
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City | SNELLVILLE
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State | GA
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Zip | 30039-8815
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Country | US
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Telephone | 770-648-6960
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Fax |
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Provider Business Mailing Address
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Address Line | 3363 PINEGATE TRL
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City | SNELLVILLE
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State | GA
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Zip | 30039-8815
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/DIRECTOR
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Name | VELENA MIXON
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Credential |
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Telephone | 404-434-6711
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | 2012013672
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License Number State | GA
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