Healthcare Provider Details

I. General information

NPI: 1467091116
Provider Name (Legal Business Name): THE EBENEZER ALF II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2019
Last Update Date: 12/29/2019
Certification Date: 12/29/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 CHAUCER AVE
LEHIGH ACRES FL
33936-7731
US

IV. Provider business mailing address

304 CHAUCER AVE
LEHIGH ACRES FL
33936-7731
US

V. Phone/Fax

Practice location:
  • Phone: 239-368-2101
  • Fax:
Mailing address:
  • Phone: 239-368-2101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: YAZMIN PEREZ
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 239-333-5920