Provider Demographics
NPI:1285005645
Name:EBENEZER HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:EBENEZER HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MYUNG
Authorized Official - Middle Name:S
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:4702-994-5464
Mailing Address - Street 1:5380 PEACHTREE INDUSTRIAL BLVD STE 247
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-1592
Mailing Address - Country:US
Mailing Address - Phone:470-299-4564
Mailing Address - Fax:
Practice Address - Street 1:5380 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 247 AB
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-4713
Practice Address - Country:US
Practice Address - Phone:470-299-4564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067-R-1183253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003160947AMedicaid