Healthcare Provider Details

I. General information

NPI: 1124202973
Provider Name (Legal Business Name): EPIPHANY HEALTHCARE SYSTEM, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 TYRONE RD STE 110
TYRONE GA
30290-2407
US

IV. Provider business mailing address

4405 MALL BLVD SUITE 518
UNION CITY GA
30291-2044
US

V. Phone/Fax

Practice location:
  • Phone: 770-306-3416
  • Fax: 770-306-3417
Mailing address:
  • Phone: 770-306-3416
  • Fax: 770-306-3417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number060-R-0322
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. DICKSON OSANU
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 770-306-3416