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Organization
DESTINY LIFE CENTER COG
Active
Organization
DESTINY LIFE CENTER COG
Active
Parent organization
GENERAL ASSEMBLY OF THE CHURCH OF GOD
Other names
Victory House for women, Victory House for women
Organization subpart
Yes
Provider details
NPI number
Legal business name
GENERAL ASSEMBLY OF THE CHURCH OF GOD
Authorized official
PATRICIA JIMERSON (EXECUTIVE DIRECTOR)
(260) 557-6183
Entity
Organization
Contact information
Practice address
518 E JEFFERSON BLVD, FORT WAYNE, IN 46802-3204
(260) 557-6183
Mailing address
518 E JEFFERSON BLVD, FORT WAYNE, IN 46802-3204
(260) 557-6183
Taxonomy
Speciality
Code
Description
License number
State
174200000X
Meals Provider
—
NULL
177F00000X
Lodging Provider
—
NULL
251S00000X
Community/Behavioral Health Agency
—
NULL
253Z00000X
In Home Supportive Care Agency
Primary
—
NULL
Other
Enumeration date
12/11/2018
Last updated
12/11/2018
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