1730244245 NPI number — EPIPHANY HOUSE, INC.

Table of content: DENNIS RAY PRYOR PHARMD. (NPI 1700103629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730244245 NPI number — EPIPHANY HOUSE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EPIPHANY HOUSE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730244245
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 GRAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASBURY PARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07712-6012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-775-0720
Provider Business Mailing Address Fax Number:
732-502-0065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
373 BRIGHTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BRANCH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07740-5201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-870-9113
Provider Business Practice Location Address Fax Number:
732-870-3372
Provider Enumeration Date:
12/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LABUNSKI
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
RUTH
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
732-775-0720

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7605404 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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