Healthcare Provider Details

I. General information

NPI: 1093627598
Provider Name (Legal Business Name): EBONEE HOUSEWORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 DRUMCLIFF CT
HEPHZIBAH GA
30815-6621
US

IV. Provider business mailing address

246 ROBT DANEL JR PKWY # 1225
AUGUSTA GA
30909-0803
US

V. Phone/Fax

Practice location:
  • Phone: 803-906-2558
  • Fax:
Mailing address:
  • Phone: 803-906-2558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code224900000X
TaxonomyMastectomy Fitter
License NumberCO1002602
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: