Healthcare Provider Details

I. General information

NPI: 1316106214
Provider Name (Legal Business Name): EPIPHANY PLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHURCH ST
MARSHAL MN
56258
US

IV. Provider business mailing address

608 VIKING DRIVE
MARSHALL MN
56258-2300
US

V. Phone/Fax

Practice location:
  • Phone: 507-532-7326
  • Fax:
Mailing address:
  • Phone: 507-532-7326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEEDE L KOEL
Title or Position: OWNER DIRECTOR PRACTITIONER
Credential: RN LPC NCC
Phone: 507-532-7326