Provider Demographics
NPI:1083963607
Name:DESTINY ADULT HOME DAY CARE
Entity Type:Organization
Organization Name:DESTINY ADULT HOME DAY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-434-6711
Mailing Address - Street 1:3363 PINEGATE TRL
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-8815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3363 PINEGATE TRL
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-8815
Practice Address - Country:US
Practice Address - Phone:770-648-6960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2012013672311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home