Provider Demographics
NPI:1093272064
Name:EKANDZA EBALE, MARIEN ULRICH
Entity Type:Individual
Prefix:
First Name:MARIEN
Middle Name:ULRICH
Last Name:EKANDZA EBALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7131 N VIA ASSISI
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-4315
Mailing Address - Country:US
Mailing Address - Phone:520-531-2364
Mailing Address - Fax:520-575-9794
Practice Address - Street 1:7131 N VIA ASSISI
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-4315
Practice Address - Country:US
Practice Address - Phone:520-531-2364
Practice Address - Fax:520-575-9794
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAL11036H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility