Provider Demographics
NPI:1356992978
Name:DESTINY MANOR
Entity type:Organization
Organization Name:DESTINY MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MAXINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-378-7962
Mailing Address - Street 1:PO BOX 383
Mailing Address - Street 2:
Mailing Address - City:ARCOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38722-0383
Mailing Address - Country:US
Mailing Address - Phone:662-378-7962
Mailing Address - Fax:662-827-7347
Practice Address - Street 1:104 MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:ARCOLA
Practice Address - State:MS
Practice Address - Zip Code:38722
Practice Address - Country:US
Practice Address - Phone:662-827-7500
Practice Address - Fax:662-827-7347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility