Healthcare Provider Details

I. General information

NPI: 1871181313
Provider Name (Legal Business Name): EBENEZER BEHAVIORAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2021
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3141 W MALDONADO RD
PHOENIX AZ
85041-6372
US

IV. Provider business mailing address

3141 W MALDONADO RD
PHOENIX AZ
85041-6372
US

V. Phone/Fax

Practice location:
  • Phone: 623-806-0479
  • Fax:
Mailing address:
  • Phone: 623-806-0479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name: ROGERS K BAGIA
Title or Position: CEO
Credential:
Phone: 623-806-0479