Provider Demographics
NPI:1528593076
Name:DESTINY HOUSING
Entity Type:Organization
Organization Name:DESTINY HOUSING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL EDIDIONG
Authorized Official - Middle Name:
Authorized Official - Last Name:UDONKANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-663-4910
Mailing Address - Street 1:18019 DIXIE HWY STE 1A
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-3058
Mailing Address - Country:US
Mailing Address - Phone:708-663-4910
Mailing Address - Fax:
Practice Address - Street 1:18019 DIXIE HWY STE 1A
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-3058
Practice Address - Country:US
Practice Address - Phone:708-663-4910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL201700004320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities