Provider Demographics
NPI:1750484085
Name:DESTINY HOME HEALTH AGENCY INC
Entity Type:Organization
Organization Name:DESTINY HOME HEALTH AGENCY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:NSEMEKE
Authorized Official - Last Name:EKPO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-242-1365
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92556-1000
Mailing Address - Country:US
Mailing Address - Phone:951-242-1365
Mailing Address - Fax:
Practice Address - Street 1:12981 PERRIS BLVD,
Practice Address - Street 2:SUITE 214
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-4112
Practice Address - Country:US
Practice Address - Phone:951-242-1365
Practice Address - Fax:951-242-1387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250000800251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1750484085Medicaid
CAHHA08263FMedicaid