Provider Demographics
NPI:1336778711
Name:ANDERSON, EPHRAIM JOSEPH
Entity Type:Individual
Prefix:
First Name:EPHRAIM
Middle Name:JOSEPH
Last Name:ANDERSON
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 1:512 N EVANSTON AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3917
Mailing Address - Country:US
Mailing Address - Phone:216-203-3653
Mailing Address - Fax:
Practice Address - Street 1:3615 19TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1203
Practice Address - Country:US
Practice Address - Phone:806-725-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner