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
State | License ID | Taxonomies |
---|---|---|
MN | 800713-2-ADC | 261QA0600X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QA0600X | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |