Healthcare Provider Details

I. General information

NPI: 1144933268
Provider Name (Legal Business Name): EBENEZER DAYBREAK OF ST. PAUL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 10TH ST W STE 3440
SAINT PAUL MN
55102-1062
US

IV. Provider business mailing address

45 10TH ST W STE 3440
SAINT PAUL MN
55102-1062
US

V. Phone/Fax

Practice location:
  • Phone: 651-328-4889
  • Fax:
Mailing address:
  • Phone: 651-328-4889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TODD WILLETT
Title or Position: CFO ACCOUNTING
Credential:
Phone: 612-874-3493