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General NPI Number Information
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NPI Number | 1356992978
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Entity Type | Organization
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Legal Business Name | DESTINY MANOR
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Dates
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Enumeration Date | 09/25/2019
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Last Update Date | 09/25/2019
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Provider Practice Location Address
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Address Line | 104 MARTIN LUTHER KING BLVD
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City | ARCOLA
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State | MS
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Zip | 38722
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Country | US
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Telephone | 662-827-7500
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Fax | 662-827-7347
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Provider Business Mailing Address
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Address Line | PO BOX 383
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City | ARCOLA
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State | MS
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Zip | 38722-0383
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Country | US
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Telephone | 662-378-7962
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Fax | 662-827-7347
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Authorized Official
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Title or Position | MANAGER
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Name | MAXINE D HARRIS
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Credential |
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Telephone | 662-378-7962
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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