MEDICARE: DESTINY ROSE RESIDENTIAL CARE FACILITY

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	310400000X	Assisted Living Facility	00000000000000000000	TX

General Provider Information

NPI Number	:	1386920536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTINY ROSE RESIDENTIAL CARE FACILITY

Provider Business Mailing Address
First Line	:	PO BOX 543174
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75054-3174
Country	:	US
Telephone Number	:	214-778-7228
Fax Number	:	214-377-5009

Provider Business Practice Location Address
First Line	:	1620 GLEN AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-1727
Country	:	US
Telephone Number	:	214-335-0627
Fax Number	:	214-941-0308

Authorized Official
Title or Position	:	OWNER
Name	:	TONI MARTIN-MOORE
Credential	:
Telephone Number	:	214-778-7228

Provider Enumeration Date	:	11/01/2011
Last Update Date	:	09/21/2021

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