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General NPI Number Information
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NPI Number | 1720402928
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Entity Type | Organization
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Legal Business Name | DESTINYS DOORS LLC
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Dates
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Enumeration Date | 02/07/2014
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Last Update Date | 02/07/2014
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Provider Practice Location Address
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Address Line | 3781 PRESIDENTIAL PKWY STE 106
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City | ATLANTA
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State | GA
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Zip | 30340-3702
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Country | US
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Telephone | 470-554-0206
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Fax |
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Provider Business Mailing Address
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Address Line | 3781 PRESIDENTIAL PKWY STE 106
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City | ATLANTA
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State | GA
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Zip | 30340-3702
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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 | CEO
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Name | MISS SHAWNTA WELCH
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Credential |
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Telephone | 470-554-0206
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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 | 14011940
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License Number State | GA
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