Provider Demographics
NPI:1831712413
Name:DESTINATION LIFE LLC-S
Entity type:Organization
Organization Name:DESTINATION LIFE LLC-S
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADM & AUTH REP
Authorized Official - Prefix:
Authorized Official - First Name:ZEMELDA
Authorized Official - Middle Name:D
Authorized Official - Last Name:CARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-473-1312
Mailing Address - Street 1:2001 SE GREEN OAKS BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-0952
Mailing Address - Country:US
Mailing Address - Phone:817-473-1312
Mailing Address - Fax:866-990-2813
Practice Address - Street 1:2001 SE GREEN OAKS BLVD STE 130
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-0952
Practice Address - Country:US
Practice Address - Phone:817-473-1312
Practice Address - Fax:866-990-2813
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESTINATION LIFE LLC-S
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-18
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No291U00000XLaboratoriesClinical Medical Laboratory
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2207166OtherCLIA
TX482228OtherPTAN
TX404951201Medicaid
MS25D2200016OtherCLIA MS
TX567960000OtherTHERAPY CLINIC