Provider Demographics
NPI:1275285850
Name:DESTINY TREATMENT CENTER LLC
Entity Type:Organization
Organization Name:DESTINY TREATMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:CATC
Authorized Official - Phone:424-342-1403
Mailing Address - Street 1:38 PARADISE VALLEY NORTH
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745
Mailing Address - Country:US
Mailing Address - Phone:424-342-1403
Mailing Address - Fax:424-287-0172
Practice Address - Street 1:5230 CLARK AVE #31
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712
Practice Address - Country:US
Practice Address - Phone:424-342-1403
Practice Address - Fax:424-287-0172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty