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General NPI Number Information
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NPI Number | 1093037566
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Entity Type | Organization
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Legal Business Name | DESTINED REVISIONS, LLC
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Dates
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Enumeration Date | 02/24/2010
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Last Update Date | 03/16/2017
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Provider Practice Location Address
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Address Line | 947 BRYANT HILL RD
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City | MARSHALLVILLE
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State | GA
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Zip | 31057-3113
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Country | US
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Telephone | 678-468-4880
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Fax |
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Provider Business Mailing Address
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Address Line | 2550 E WESLEY CHAPEL WAY STE 5
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City | DECATUR
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State | GA
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Zip | 30035-3430
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Country | US
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Telephone | 678-468-4880
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MISS JOY JUNESE GRIER
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Credential | B.S
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Telephone | 678-468-4880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | GA
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