MEDICARE: DESTINY'S FULFILLED INC

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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	SS06320	VA

General Provider Information

NPI Number	:	1831254119
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTINY'S FULFILLED INC

Provider Business Mailing Address
First Line	:	1908 CHEVELLE DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23235-5641
Country	:	US
Telephone Number	:	804-276-1702
Fax Number	:	804-276-6051

Provider Business Practice Location Address
First Line	:	1908 CHEVELLE DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23235-5641
Country	:	US
Telephone Number	:	804-276-1702
Fax Number	:	804-276-6051

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFIER
Name	:	MISS STACEY M COOK
Credential	:
Telephone Number	:	804-276-1702

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	08/22/2020

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