Provider Demographics
NPI:1356636344
Name:EBENEZER HOME CARE
Entity Type:Organization
Organization Name:EBENEZER HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRYGAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-874-3477
Mailing Address - Street 1:2625 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1016
Mailing Address - Country:US
Mailing Address - Phone:612-871-4574
Mailing Address - Fax:612-872-7368
Practice Address - Street 1:2625 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1016
Practice Address - Country:US
Practice Address - Phone:612-871-4574
Practice Address - Fax:612-872-7368
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EBENEZER SOCIETY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-17
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27773251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health