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
—
—
177F00000X
Lodging Provider
—
—
251S00000X
Community/Behavioral Health Agency
—
—
253Z00000X
In Home Supportive Care Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05
—
IN
01
—
35257218
RECOVERY WORKS HOUSING
IN
Enumeration date
12/11/2018
Last updated
12/11/2018
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