Healthcare Provider Details

I. General information

NPI: 1386186534
Provider Name (Legal Business Name): YOUR DESTINY MINISTRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14819 PLYMOUTH RD
DETROIT MI
48227-2443
US

IV. Provider business mailing address

8226 PEMBROKE AVE
DETROIT MI
48221-1160
US

V. Phone/Fax

Practice location:
  • Phone: 123-168-3659
  • Fax:
Mailing address:
  • Phone: 123-168-3659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateMI

VIII. Authorized Official

Name: MR. ANTHONY HOWARD SPICER JR.
Title or Position: PASTOR/PRESIDENT
Credential:
Phone: 12316836592