Destiny Life Center Cog

Primary specialty

In Home Supportive Care AgencyTaxonomy code 253Z00000X

Legal business name

DESTINY LIFE CENTER COG

Practice address

518 E Jefferson Blvd
Fort Wayne, IN 46802-3204

Phone

(260) 557-6183

NPI assigned

Dec 11, 2018

Organization subpart

Yes

Parent organization

GENERAL ASSEMBLY OF THE CHURCH OF GODAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Patricia Jimerson

Title

Executive Director

Phone

(260) 557-6183

Specialties & licenses 4

Addresses

Other identifiers 2

Other names 1

• Victory House for women Other name

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1544486400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1544486400000",
    "number": "1679044960",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "518 E JEFFERSON BLVD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468023204",
            "telephone_number": "260-557-6183"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "518 E JEFFERSON BLVD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468023204",
            "telephone_number": "260-557-6183"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DESTINY LIFE CENTER COG",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "GENERAL ASSEMBLY OF THE CHURCH OF GOD",
        "enumeration_date": "2018-12-11",
        "last_updated": "2018-12-11",
        "status": "A",
        "authorized_official_last_name": "JIMERSON",
        "authorized_official_first_name": "PATRICIA",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "260-557-6183"
    },
    "taxonomies": [
        {
            "code": "174200000X",
            "taxonomy_group": "",
            "desc": "Meals",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "177F00000X",
            "taxonomy_group": "",
            "desc": "Lodging",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "253Z00000X",
            "taxonomy_group": "",
            "desc": "In Home Supportive Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "05",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RECOVERY WORKS HOUSING",
            "identifier": "35257218",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Victory House for women",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Victory House for women",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Luretta S Deschner, MD
• William P. Deschner, MD
• Kiarrie Deshazior
• James Desimone, M.D.
• Angela C Despenza, LPN
• Kristi Detar, RBT
• Hannah Kay Detmer
• Alyssa L. Detommaso, PA-C
• Dominick Detommaso, D.P.M.
• Jonathan Detommaso, DPM

• In Home Supportive Care Agency in Fort Wayne, IN
• Providers in Fort Wayne, IN by specialty
• In Home Supportive Care Agency in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 11, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.