Provider Demographics
NPI:1679044960
Name:DESTINY LIFE CENTER COG
Entity Type:Organization
Organization Name:DESTINY LIFE CENTER COG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-557-6183
Mailing Address - Street 1:518 E JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-3204
Mailing Address - Country:US
Mailing Address - Phone:260-557-6183
Mailing Address - Fax:
Practice Address - Street 1:518 E JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-3204
Practice Address - Country:US
Practice Address - Phone:260-557-6183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENERAL ASSEMBLY OF THE CHURCH OF GOD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No174200000XOther Service ProvidersMeals
No177F00000XOther Service ProvidersLodging
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN05Medicaid
IN35257218OtherRECOVERY WORKS HOUSING