Provider Demographics
NPI:1720593627
Name:DESTINED FOR CHANGE LLC
Entity Type:Organization
Organization Name:DESTINED FOR CHANGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHAVARRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-867-0053
Mailing Address - Street 1:2094 W BUSCH BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-7568
Mailing Address - Country:US
Mailing Address - Phone:813-867-0053
Mailing Address - Fax:877-349-6369
Practice Address - Street 1:2094 W BUSCH BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-7568
Practice Address - Country:US
Practice Address - Phone:813-867-0053
Practice Address - Fax:877-349-6369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-13
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty