Provider Demographics
NPI:1669874673
Name:EBENEZER HEALTHCARE SERVICES, INC.
Entity type:Organization
Organization Name:EBENEZER HEALTHCARE SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MYUNG
Authorized Official - Middle Name:SOOK
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-483-6493
Mailing Address - Street 1:4405 INTERNATIONAL BLVD
Mailing Address - Street 2:SUITE B101
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-3019
Mailing Address - Country:US
Mailing Address - Phone:770-806-0009
Mailing Address - Fax:770-806-0100
Practice Address - Street 1:4405 INTERNATIONAL BLVD
Practice Address - Street 2:SUITE B101
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-3019
Practice Address - Country:US
Practice Address - Phone:770-806-0009
Practice Address - Fax:770-806-0100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067-R-1183261QA0600X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care