Provider Demographics
NPI:1891764882
Name:DESTINY'S FULFILLED L.L.C.
Entity Type:Organization
Organization Name:DESTINY'S FULFILLED L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECTUIVE OFFICER
Authorized Official - Prefix:MISS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-276-1702
Mailing Address - Street 1:PO BOX 74924
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23236-0016
Mailing Address - Country:US
Mailing Address - Phone:804-276-1702
Mailing Address - Fax:804-276-6051
Practice Address - Street 1:1908 CHEVELLE DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-5641
Practice Address - Country:US
Practice Address - Phone:804-276-1702
Practice Address - Fax:804-276-6051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA320-2006320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities