Provider Demographics
NPI:1477968550
Name:EBENEZER SOCIETY, LLC
Entity Type:Organization
Organization Name:EBENEZER SOCIETY, LLC
Other - Org Name:EBENEZER HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF HOUSING DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:NOKLEBY
Authorized Official - Last Name:KAISER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-874-3431
Mailing Address - Street 1:25565 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-8053
Mailing Address - Country:US
Mailing Address - Phone:651-982-6228
Mailing Address - Fax:
Practice Address - Street 1:25565 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092-8053
Practice Address - Country:US
Practice Address - Phone:651-982-6228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23170251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health