Provider Demographics
NPI:1811363682
Name:GYIMAH SARPONG, EBENEZER
Entity Type:Individual
Prefix:
First Name:EBENEZER
Middle Name:
Last Name:GYIMAH SARPONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 WINDBREAK DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-2605
Mailing Address - Country:US
Mailing Address - Phone:571-420-7032
Mailing Address - Fax:
Practice Address - Street 1:8111 TIS WELL DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3211
Practice Address - Country:US
Practice Address - Phone:703-360-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility