Provider Demographics
NPI:1679196349
Name:EBONY HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:EBONY HEALTHCARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALISTS
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-484-3879
Mailing Address - Street 1:169 PARKVIEW RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-9671
Mailing Address - Country:US
Mailing Address - Phone:912-677-8231
Mailing Address - Fax:888-494-4209
Practice Address - Street 1:169 PARKVIEW RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-9671
Practice Address - Country:US
Practice Address - Phone:912-677-8231
Practice Address - Fax:888-494-4209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-28
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty