MEDICARE: DESTINY COUNTRYMAN

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1205667730
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY COUNTRYMAN

Provider Business Mailing Address
First Line	:	22225 FENKELL ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48223-1534
Country	:	US
Telephone Number	:	313-900-1326
Fax Number	:

Provider Business Practice Location Address
First Line	:	22225 FENKELL ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48223-1534
Country	:	US
Telephone Number	:	313-900-1326
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2024
Last Update Date	:	08/07/2024

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Directions to “ DESTINY COUNTRYMAN ” Practice Location

Language	Start Address	Practice Location

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