MEDICARE: EBENEZER ADULT DAY PROGRAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA0600X	Adult Day Care Clinic/Center	800713-2-ADC	MN

General Provider Information

NPI Number	:	1174508873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EBENEZER ADULT DAY PROGRAM

Provider Business Mailing Address
First Line	:	2545 PORTLAND AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4406
Country	:	US
Telephone Number	:	612-879-2262
Fax Number	:	612-879-2316

Provider Business Practice Location Address
First Line	:	2545 PORTLAND AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4406
Country	:	US
Telephone Number	:	612-879-2262
Fax Number	:	612-879-2316

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	MARK THOMAS
Credential	:
Telephone Number	:	612-874-3460

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	08/22/2020

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