Provider Demographics
NPI:1558796326
Name:EBENEZER MEDICAL OUTREACH INC
Entity Type:Organization
Organization Name:EBENEZER MEDICAL OUTREACH INC
Other - Org Name:EBENEZER MEDICAL OUTREACH, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FINLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-529-0753
Mailing Address - Street 1:1448 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3581
Mailing Address - Country:US
Mailing Address - Phone:304-529-0753
Mailing Address - Fax:304-529-0591
Practice Address - Street 1:1448 10TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3581
Practice Address - Country:US
Practice Address - Phone:304-529-0753
Practice Address - Fax:304-529-0591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-11
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVCC05590593336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142452OtherPK