=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306513338
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EPIPHANY CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2021
-----------------------------------------------------
Last Update Date | 08/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 RIVERSIDE DR
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55808-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-900-0111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8260 BENWOOD CIR
-----------------------------------------------------
City | CHANHASSEN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55317-9380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-900-0111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DEREK SLAUGHTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-587-2073
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------