Provider Demographics
NPI:1124202973
Name:EPIPHANY HEALTHCARE SYSTEM, INC
Entity Type:Organization
Organization Name:EPIPHANY HEALTHCARE SYSTEM, INC
Other - Org Name:ACCESSIBLE HEALTH CARE OF SOUTH ATLANTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DICKSON
Authorized Official - Middle Name:
Authorized Official - Last Name:OSANU
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:770-306-3416
Mailing Address - Street 1:4405 MALL BLVD
Mailing Address - Street 2:SUITE 518
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-2044
Mailing Address - Country:US
Mailing Address - Phone:770-306-3416
Mailing Address - Fax:770-306-3417
Practice Address - Street 1:1015 TYRONE RD STE 110
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-2407
Practice Address - Country:US
Practice Address - Phone:770-306-3416
Practice Address - Fax:770-306-3417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060-R-0322251E00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health