MEDICARE: DESTINATION LIFE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	163W00000X	Registered Nurse
2	224Z00000X	Occupational Therapy Assistant
3	225X00000X	Occupational Therapist
4	251E00000X	Home Health Agency	TX
5	253Z00000X	In Home Supportive Care Agency
6	305S00000X	Point of Service
7	314000000X	Skilled Nursing Facility
8	332B00000X	Durable Medical Equipment & Medical Supplies
9	3747P1801X	Personal Care Attendant
10	374U00000X	Home Health Aide
11	251E00000X	Home Health Agency

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	482228	OTHER	TX	MEDICARE PTAN
5	324611YS3B	OTHER	TX	GROUP MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1114328416	OTHER	TX	NIP
2	567960000	OTHER	TX	FACILITY LICENSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	567960000	OTHER	TX	LICENSE
9	7760000001	OTHER	TX	DME
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114328416
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTINATION LIFE LLC

Provider Business Mailing Address
First Line	:	2001 SE GREEN OAKS BLVD STE 130
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76018-0952
Country	:	US
Telephone Number	:	817-473-1312
Fax Number	:	866-990-2813

Provider Business Practice Location Address
First Line	:	2001 SE GREEN OAKS BLVD STE 130
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76018-0952
Country	:	US
Telephone Number	:	817-473-1312
Fax Number	:	866-990-2813

Authorized Official
Title or Position	:	ADM AND AUTH REP
Name	:	ZEMELDA D. CARR
Credential	:
Telephone Number	:	817-473-1312

Provider Enumeration Date	:	09/06/2014
Last Update Date	:	07/21/2022

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Directions to “DESTINATION LIFE LLC ” Practice Location

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