DESTINATION LIFE LLC

Provider Demographics

• NPI: 1629691167
• Name: DESTINATION LIFE LLC
• Entity Type: Organization
• Organization Name: DESTINATION LIFE LLC
• Other - Org Name: SAJOURNEY
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: ADM & AUTH REP
• Authorized Official - First Name: ZEMELDA
• Authorized Official - Middle Name: D
• Authorized Official - Last Name: CARR
• Authorized Official - Phone: 817-473-1312
• Mailing Address - Street 1: 2001 SE GREEN OAKS BLVD STE 130
• Mailing Address - City: ARLINGTON
• Mailing Address - State: TX
• Mailing Address - Zip Code: 76018-0952
• Mailing Address - Country: US
• Mailing Address - Phone: 817-473-1312
• Mailing Address - Fax: 866-990-2813
• Practice Address - Street 1: 2001 SE GREEN OAKS BLVD STE 130
• Practice Address - City: ARLINGTON
• Practice Address - State: TX
• Practice Address - Zip Code: 76018-0952
• Practice Address - Country: US
• Practice Address - Phone: 817-473-1312
• Practice Address - Fax: 866-990-2813
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: DESTINATION LIFE LLC
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2020-05-19
• Last Update Date: 2022-03-16

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	225X00000X	Respiratory, Developmental, Rehabilitative and Restorative Service Providers	Occupational Therapist		Group - Multi-Specialty
No	104100000X	Behavioral Health & Social Service Providers	Social Worker		Group - Multi-Specialty
No	207KI0005X	Allopathic & Osteopathic Physicians	Allergy & Immunology	Clinical & Laboratory Immunology	Group - Multi-Specialty
No	251B00000X	Agencies	Case Management		Group - Multi-Specialty
No	251J00000X	Agencies	Nursing Care		Group - Multi-Specialty
No	261QM0801X	Ambulatory Health Care Facilities	Clinic/Center	Mental Health (Including Community Mental Health Center)	Group - Multi-Specialty
No	261QM0850X	Ambulatory Health Care Facilities	Clinic/Center	Adult Mental Health	Group - Multi-Specialty
No	261QM0855X	Ambulatory Health Care Facilities	Clinic/Center	Adolescent and Children Mental Health	Group - Multi-Specialty
No	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Multi-Specialty
No	363LA2200X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Adult Health	Group - Multi-Specialty
No	363LP0808X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Psychiatric/Mental Health	Group - Multi-Specialty
No	363LP2300X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Primary Care	Group - Multi-Specialty
No	363LW0102X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Women's Health	Group - Multi-Specialty
No	364SP0807X	Physician Assistants & Advanced Practice Nursing Providers	Clinical Nurse Specialist	Psychiatric/Mental Health, Child & Adolescent	Group - Multi-Specialty
No	364SP0809X	Physician Assistants & Advanced Practice Nursing Providers	Clinical Nurse Specialist	Psychiatric/Mental Health, Adult	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
MS	25D2200016	Other	CLIA
MS	03320311	Medicaid
TX	404951201	Medicaid