Healthcare Provider Details

I. General information

NPI: 1720389000
Provider Name (Legal Business Name): TERRANCE DESMOND EPPENGER HHA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 HUEY ST
SOUTH BEND IN
46628-2509
US

IV. Provider business mailing address

906 HUEY ST
SOUTH BEND IN
46628-2509
US

V. Phone/Fax

Practice location:
  • Phone: 574-229-3318
  • Fax:
Mailing address:
  • Phone: 574-229-3318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberHHA0800371
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: