Healthcare Provider Details

I. General information

NPI: 1063368736
Provider Name (Legal Business Name): ELIZABETH EBOW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2026
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 CHERRY AVE
LONG BEACH CA
90813-2519
US

IV. Provider business mailing address

PO BOX 56875
LOS ANGELES CA
90056-0148
US

V. Phone/Fax

Practice location:
  • Phone: 323-402-1564
  • Fax: 323-402-9010
Mailing address:
  • Phone: 323-402-1564
  • Fax: 323-402-9010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: