Provider Demographics
NPI:1407426273
Name:EBENEZER HOUSE I , LLC
Entity Type:Organization
Organization Name:EBENEZER HOUSE I , LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:NIBIZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-440-4404
Mailing Address - Street 1:11114 W COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-1269
Mailing Address - Country:US
Mailing Address - Phone:623-440-4404
Mailing Address - Fax:
Practice Address - Street 1:4055 N 77TH DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-3618
Practice Address - Country:US
Practice Address - Phone:623-440-4404
Practice Address - Fax:623-777-0082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0000Medicaid