Provider Demographics
NPI:1508293465
Name:DESTINY MEDICAL SERVICES, INC
Entity Type:Organization
Organization Name:DESTINY MEDICAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO'
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-964-1474
Mailing Address - Street 1:2774 N COBB PKWY
Mailing Address - Street 2:SUITE 109, #133
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-3469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2804 N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-5914
Practice Address - Country:US
Practice Address - Phone:229-241-8925
Practice Address - Fax:229-241-9165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-08
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA41426208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty