MEDICARE: DESTINY MEDICAL SUPPLIES INC.,

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	0055999	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	102881	OTHER	TX	AMERIGROUP ID#

General Provider Information

NPI Number	:	1366448797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESTINY MEDICAL SUPPLIES INC.,

Provider Business Mailing Address
First Line	:	PO BOX 51088
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76105-8088
Country	:	US
Telephone Number	:	817-534-2770
Fax Number	:	817-534-2977

Provider Business Practice Location Address
First Line	:	4735 E LANCASTER AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-3835
Country	:	US
Telephone Number	:	817-534-2770
Fax Number	:	817-534-2977

Authorized Official
Title or Position	:	CEO
Name	:	MR. CHRISTOPHER PAUL BASSEY
Credential	:
Telephone Number	:	817-534-2770

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	08/22/2020

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