Provider Demographics
NPI:1407019227
Name:EBENEZER SUPPLIES INC
Entity Type:Organization
Organization Name:EBENEZER SUPPLIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GODWIN
Authorized Official - Middle Name:O
Authorized Official - Last Name:ENYONG
Authorized Official - Suffix:JR
Authorized Official - Credentials:INC
Authorized Official - Phone:318-868-1349
Mailing Address - Street 1:2924 KNIGHT ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-2413
Mailing Address - Country:US
Mailing Address - Phone:318-868-1349
Mailing Address - Fax:318-868-1350
Practice Address - Street 1:2924 KNIGHT ST STE 412
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2413
Practice Address - Country:US
Practice Address - Phone:318-868-1349
Practice Address - Fax:318-868-1350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies