Provider Demographics
NPI:1245583194
Name:DESTINED 4 GREATNESS
Entity Type:Organization
Organization Name:DESTINED 4 GREATNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-597-9490
Mailing Address - Street 1:698 GRAND FOLIA CT
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-5593
Mailing Address - Country:US
Mailing Address - Phone:404-597-9490
Mailing Address - Fax:
Practice Address - Street 1:698 GRAND FOLIA CT
Practice Address - Street 2:
Practice Address - City:SUGAR HILL
Practice Address - State:GA
Practice Address - Zip Code:30518-5593
Practice Address - Country:US
Practice Address - Phone:404-597-9490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-16
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGAMedicaid