Provider Demographics
NPI:1235847138
Name:DESTINY CARE
Entity Type:Organization
Organization Name:DESTINY CARE
Other - Org Name:DESTINY CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANYELL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-493-0808
Mailing Address - Street 1:3232 RIVER VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-8090
Mailing Address - Country:US
Mailing Address - Phone:901-493-0808
Mailing Address - Fax:
Practice Address - Street 1:3232 RIVER VALLEY LN
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8090
Practice Address - Country:US
Practice Address - Phone:901-493-0808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-09
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1000000031843OtherLICENSE NUMBER