Provider Demographics
NPI:1114551116
Name:EBENEZER REST HOME LLC
Entity Type:Organization
Organization Name:EBENEZER REST HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:F
Authorized Official - Last Name:NAMULONDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-244-7270
Mailing Address - Street 1:18909 RED OAK LN
Mailing Address - Street 2:
Mailing Address - City:TRIANGLE
Mailing Address - State:VA
Mailing Address - Zip Code:22172-2122
Mailing Address - Country:US
Mailing Address - Phone:812-447-2707
Mailing Address - Fax:
Practice Address - Street 1:18909 RED OAK LN
Practice Address - Street 2:
Practice Address - City:TRIANGLE
Practice Address - State:VA
Practice Address - Zip Code:22172-2122
Practice Address - Country:US
Practice Address - Phone:812-447-2707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA02272020OtherASSISTED LIVING FACILITY