Provider Demographics
NPI:1417426156
Name:MY DESTINEE HOME HEALTH, LLC
Entity Type:Organization
Organization Name:MY DESTINEE HOME HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:JERR'KA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCAULEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-625-7233
Mailing Address - Street 1:2836 OHIO AVE APT A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-1516
Mailing Address - Country:US
Mailing Address - Phone:314-625-7233
Mailing Address - Fax:314-528-5294
Practice Address - Street 1:2836 OHIO AVE APT A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-1516
Practice Address - Country:US
Practice Address - Phone:314-625-7233
Practice Address - Fax:314-528-5294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-23
Last Update Date:2018-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT1019Medicaid