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General NPI Number Information
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NPI Number | 1790493336
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Entity Type | Organization
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Legal Business Name | DESTINED FOR GREATNESS
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Dates
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Enumeration Date | 11/14/2022
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Last Update Date | 11/14/2022
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Provider Practice Location Address
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Address Line | 274 VOLZ AVE
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City | RIPLEY
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State | TN
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Zip | 38063-2078
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Country | US
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Telephone | 731-671-8273
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Fax |
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Provider Business Mailing Address
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Address Line | 274 VOLZ AVE
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City | RIPLEY
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State | TN
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Zip | 38063-2078
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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
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Name | LAKILI TREADWAY
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Credential |
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Telephone | 731-671-8273
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 247ZC0005X
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Taxonomy Name | Clinical Laboratory Director (Non-physician)
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License Number |
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License Number State |
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