Provider Demographics
NPI:1417434606
Name:EPIPHANY HEALTHCARE OF HAMMOND
Entity type:Organization
Organization Name:EPIPHANY HEALTHCARE OF HAMMOND
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:985-209-6571
Mailing Address - Street 1:11059 PHYLLISS LN
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-1102
Mailing Address - Country:US
Mailing Address - Phone:985-209-6571
Mailing Address - Fax:
Practice Address - Street 1:11059 PHYLLISS LN
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-1102
Practice Address - Country:US
Practice Address - Phone:985-209-6571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-20
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WH0200X, 2279H0200X, 251E00000X
LA2203783830405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
No2279H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredHome HealthGroup - Multi-Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2203783830Medicaid