Provider Demographics
NPI:1457998551
Name:NEW DESTINY HEALTH LLC
Entity Type:Organization
Organization Name:NEW DESTINY HEALTH LLC
Other - Org Name:NEW DESTINY HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER-MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLANOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-522-0566
Mailing Address - Street 1:530 E HUNT HWY
Mailing Address - Street 2:SUITE 103-188
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143
Mailing Address - Country:US
Mailing Address - Phone:480-522-0566
Mailing Address - Fax:
Practice Address - Street 1:1072 E DRAGON FLY RD
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85143
Practice Address - Country:US
Practice Address - Phone:480-522-0566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-08
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness