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General NPI Number Information
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NPI Number | 1295965473
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Entity Type | Organization
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Legal Business Name | DESTINY HOME, INC. #2
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Dates
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Enumeration Date | 07/21/2009
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Last Update Date | 07/21/2009
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Provider Practice Location Address
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Address Line | 1708 VINTAGE RD
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City | RALEIGH
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State | NC
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Zip | 27610-3187
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Country | US
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Telephone | 919-454-7725
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Fax | 919-231-3736
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Provider Business Mailing Address
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Address Line | 234 SEVEN OAKS RD
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City | DURHAM
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State | NC
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Zip | 27704-1125
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Country | US
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Telephone | 919-454-7725
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Fax | 919-231-3736
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Authorized Official
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Title or Position | CEO
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Name | OSWALD NWOGBO
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Credential |
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Telephone | 919-454-7725
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | MHL-032-487
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License Number State | NC
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