Healthcare Provider Details

I. General information

NPI: 1417434606
Provider Name (Legal Business Name): EPIPHANY HEALTHCARE OF HAMMOND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11059 PHYLLISS LN
HAMMOND LA
70401-1102
US

IV. Provider business mailing address

11059 PHYLLISS LN
HAMMOND LA
70401-1102
US

V. Phone/Fax

Practice location:
  • Phone: 985-209-6571
  • Fax:
Mailing address:
  • Phone: 985-209-6571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2279H0200X
TaxonomyHome Health Registered Respiratory Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number2203783830
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRISTOPHER MOORE
Title or Position: CEO, EXECUTIVE DIRECTOR
Credential:
Phone: 985-209-6571