Provider Demographics
NPI:1154074730
Name:SCULPTED BODIES BY DESTANI LLC.
Entity Type:Organization
Organization Name:SCULPTED BODIES BY DESTANI LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DESTYNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-260-9062
Mailing Address - Street 1:2205 OUSLEYDALE RD
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-8733
Mailing Address - Country:US
Mailing Address - Phone:843-260-9062
Mailing Address - Fax:
Practice Address - Street 1:2205 OUSLEYDALE RD
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-8733
Practice Address - Country:US
Practice Address - Phone:843-260-9062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service