Provider Demographics
NPI:1821794454
Name:NEW DESTINY HEALING LLC
Entity Type:Organization
Organization Name:NEW DESTINY HEALING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLANOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-710-2595
Mailing Address - Street 1:530 E HUNT HWY STE 103-188
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5226
Mailing Address - Country:US
Mailing Address - Phone:626-710-2595
Mailing Address - Fax:
Practice Address - Street 1:2011 W HALF MOON CIR
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85142-4461
Practice Address - Country:US
Practice Address - Phone:626-710-2595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW DESTINY HEALING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness