Provider Demographics
NPI:1245884048
Name:EPHPHATHA MEDICAL CARE SERVICES LLC
Entity type:Organization
Organization Name:EPHPHATHA MEDICAL CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:EMANIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:DORIVAL
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:925-222-9572
Mailing Address - Street 1:23092 MEADOW WOOD CT UNIT 416
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-7753
Mailing Address - Country:US
Mailing Address - Phone:925-222-9572
Mailing Address - Fax:
Practice Address - Street 1:23092 MEADOW WOOD CT UNIT 416
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-7753
Practice Address - Country:US
Practice Address - Phone:925-222-9572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-30
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty