Provider Demographics
NPI:1013503747
Name:DESTINY AWAKENING HEALTHCARE SERVICES LLC
Entity Type:Organization
Organization Name:DESTINY AWAKENING HEALTHCARE SERVICES LLC
Other - Org Name:DESTINY CAREGIVERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:EMEFA
Authorized Official - Last Name:NYOMI-EZERANUNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-704-8769
Mailing Address - Street 1:458 IRVINE TURNER BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07108-2414
Mailing Address - Country:US
Mailing Address - Phone:973-704-8769
Mailing Address - Fax:862-305-3790
Practice Address - Street 1:458 IRVINE TURNER BLVD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07108-2414
Practice Address - Country:US
Practice Address - Phone:973-704-8769
Practice Address - Fax:862-305-3790
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:-
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-16
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJHP0311900Medicaid