Provider Demographics
NPI:1356369995
Name:DESTINY HEALTHCARE INTERNATIONAL, INC
Entity type:Organization
Organization Name:DESTINY HEALTHCARE INTERNATIONAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:KIDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-339-3378
Mailing Address - Street 1:1417 S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1715
Mailing Address - Country:US
Mailing Address - Phone:605-339-3378
Mailing Address - Fax:605-339-0710
Practice Address - Street 1:1417 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1715
Practice Address - Country:US
Practice Address - Phone:605-339-3378
Practice Address - Fax:605-339-0710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1799207Q00000X
SD3601208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6701870Medicaid
SD5604647Medicaid
SD5604647Medicaid
SD100662Medicare ID - Type UnspecifiedDR. HOFER
SD100572Medicare ID - Type UnspecifiedDR. KIDMAN
SDE24161Medicare UPIN