Provider Demographics
NPI:1417639980
Name:EBENEZER HOUSE D LLC
Entity Type:Organization
Organization Name:EBENEZER HOUSE D LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KAYITESI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-239-0971
Mailing Address - Street 1:2846 W MILA WAY
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85144-6700
Mailing Address - Country:US
Mailing Address - Phone:207-239-0971
Mailing Address - Fax:
Practice Address - Street 1:2846 W MILA WAY
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85144-6700
Practice Address - Country:US
Practice Address - Phone:207-239-0971
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EBENEZER HOUSE D LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities