Provider Demographics
NPI:1174508873
Name:EBENEZER ADULT DAY PROGRAM
Entity type:Organization
Organization Name:EBENEZER ADULT DAY PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-874-3460
Mailing Address - Street 1:2545 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4406
Mailing Address - Country:US
Mailing Address - Phone:612-879-2262
Mailing Address - Fax:612-879-2316
Practice Address - Street 1:2545 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4406
Practice Address - Country:US
Practice Address - Phone:612-879-2262
Practice Address - Fax:612-879-2316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN800713-2-ADC261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care