Provider Demographics
NPI:1386937159
Name:EPIPHANY CENTER ROME, INC
Entity type:Organization
Organization Name:EPIPHANY CENTER ROME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIKA
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-500-5062
Mailing Address - Street 1:308 GLEN MILNER BLVD
Mailing Address - Street 2:SUITE 16
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3268
Mailing Address - Country:US
Mailing Address - Phone:706-234-4900
Mailing Address - Fax:706-234-9945
Practice Address - Street 1:308 GLEN MILNER BLVD
Practice Address - Street 2:SUITE 16
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3268
Practice Address - Country:US
Practice Address - Phone:706-234-4900
Practice Address - Fax:706-234-9945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10109M261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone