Provider Demographics
NPI:1538671953
Name:THE EBENEZER ALF, LLC
Entity Type:Organization
Organization Name:THE EBENEZER ALF, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:YAZMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-333-5920
Mailing Address - Street 1:348 ROCKLAND ST
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33972-5004
Mailing Address - Country:US
Mailing Address - Phone:239-333-5920
Mailing Address - Fax:
Practice Address - Street 1:348 ROCKLAND ST
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33972-5004
Practice Address - Country:US
Practice Address - Phone:239-333-5920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility