Provider Demographics
NPI:1912377979
Name:DESTINY FAMILY AND PEDIATRIC CLINIC
Entity Type:Organization
Organization Name:DESTINY FAMILY AND PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LINUS
Authorized Official - Middle Name:N
Authorized Official - Last Name:NWANNA
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE
Authorized Official - Phone:832-274-5457
Mailing Address - Street 1:4006 CREEK RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-2342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4006 CREEK RIDGE LN
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-2342
Practice Address - Country:US
Practice Address - Phone:832-274-5457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-03
Last Update Date:2015-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care