Provider Demographics
NPI:1366448797
Name:DESTINY MEDICAL SUPPLIES INC.,
Entity Type:Organization
Organization Name:DESTINY MEDICAL SUPPLIES INC.,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:BASSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-534-2770
Mailing Address - Street 1:PO BOX 51088
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76105-8088
Mailing Address - Country:US
Mailing Address - Phone:817-534-2770
Mailing Address - Fax:817-534-2977
Practice Address - Street 1:4735 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76103-3835
Practice Address - Country:US
Practice Address - Phone:817-534-2770
Practice Address - Fax:817-534-2977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0055999332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102881OtherAMERIGROUP ID#
TX102881OtherAMERIGROUP ID#