Healthcare Provider Details

I. General information

NPI: 1255631933
Provider Name (Legal Business Name): EBEN-EZER HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 10/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 PALOMA BLANCA DR
CHAPARRAL NM
88081-7821
US

IV. Provider business mailing address

524 PALOMA BLANCA DR
CHAPARRAL NM
88081-7821
US

V. Phone/Fax

Practice location:
  • Phone: 575-824-5320
  • Fax:
Mailing address:
  • Phone: 575-824-5320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number012713
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number33853312
License Number StateNM

VIII. Authorized Official

Name: ANGELES M DEAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 575-824-5320