Healthcare Provider Details

I. General information

NPI: 1174508873
Provider Name (Legal Business Name): EBENEZER ADULT DAY PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 PORTLAND AVE
MINNEAPOLIS MN
55404-4406
US

IV. Provider business mailing address

2545 PORTLAND AVE
MINNEAPOLIS MN
55404-4406
US

V. Phone/Fax

Practice location:
  • Phone: 612-879-2262
  • Fax: 612-879-2316
Mailing address:
  • Phone: 612-879-2262
  • Fax: 612-879-2316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number800713-2-ADC
License Number StateMN

VIII. Authorized Official

Name: MARK THOMAS
Title or Position: PRESIDENT/CEO
Credential:
Phone: 612-874-3460