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	License Number State
1	332BC3200X	Customized Equipment (DME)
2	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7760000001	OTHER	TX	DME

General Provider Information

NPI Number	:	1588287163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTINATION LIFE LLC

Provider Business Mailing Address
First Line	:	1759 BROAD PARK CIR S STE 113
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-7836
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 & AUTH REP
Name	:	ZEMELDA D. CARR
Credential	:
Telephone Number	:	817-473-1312

Provider Enumeration Date	:	05/18/2020
Last Update Date	:	07/30/2021

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Directions to “DESTINATION LIFE LLC ” Practice Location

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