Provider Demographics
NPI:1477041630
Name:EPIPHANY HEALTHCARE OF HAMMOND
Entity type:Organization
Organization Name:EPIPHANY HEALTHCARE OF HAMMOND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position: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:CEO
Authorized Official - Phone:985-222-4050
Mailing Address - Street 1:906 CM FAGAN DRIVE BLDG A STE 6A
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403
Mailing Address - Country:US
Mailing Address - Phone:985-222-4050
Mailing Address - Fax:985-956-7371
Practice Address - Street 1:906 CM FAGAN DRIVE BLDG A STE 6A
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403
Practice Address - Country:US
Practice Address - Phone:985-956-7370
Practice Address - Fax:985-956-7371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA22037838302084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty