Provider Demographics
NPI:1699408443
Name:EBENEZER GROUP HOME
Entity Type:Organization
Organization Name:EBENEZER GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:WILTON
Authorized Official - Middle Name:B
Authorized Official - Last Name:TRAVERS
Authorized Official - Suffix:
Authorized Official - Credentials:BSN
Authorized Official - Phone:701-730-7944
Mailing Address - Street 1:1781 35TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4875
Mailing Address - Country:US
Mailing Address - Phone:701-730-7944
Mailing Address - Fax:
Practice Address - Street 1:1781 35TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4875
Practice Address - Country:US
Practice Address - Phone:701-730-7944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND0005876569Medicaid