Provider Demographics
NPI:1790493336
Name:DESTINED FOR GREATNESS
Entity Type:Organization
Organization Name:DESTINED FOR GREATNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAKILI
Authorized Official - Middle Name:
Authorized Official - Last Name:TREADWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-671-8273
Mailing Address - Street 1:274 VOLZ AVE
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:TN
Mailing Address - Zip Code:38063-2078
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:274 VOLZ AVE
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063-2078
Practice Address - Country:US
Practice Address - Phone:731-671-8273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Single Specialty