Provider Demographics
NPI:1194852616
Name:EBENEZER HOME HEALTH CARE LLC
Entity Type:Organization
Organization Name:EBENEZER HOME HEALTH CARE LLC
Other - Org Name:EBENEZER HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-289-9400
Mailing Address - Street 1:1515 E. KEARNEY ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-2688
Mailing Address - Country:US
Mailing Address - Phone:972-289-9400
Mailing Address - Fax:972-289-9402
Practice Address - Street 1:1515 E KEARNEY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-7545
Practice Address - Country:US
Practice Address - Phone:972-289-9400
Practice Address - Fax:972-289-9402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX010358251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX677948Medicare ID - Type UnspecifiedPROVIDER NUMBER
TX677948Medicare Oscar/Certification