Healthcare Provider Details

I. General information

NPI: 1184381246
Provider Name (Legal Business Name): EBENEZER MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2021
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2619 W CHARLESTON BLVD STE E
LAS VEGAS NV
89102-2121
US

IV. Provider business mailing address

305 ANTELOPE WAY
LAS VEGAS NV
89145-5201
US

V. Phone/Fax

Practice location:
  • Phone: 702-805-3059
  • Fax:
Mailing address:
  • Phone: 702-515-9926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: YAREL HERNANDEZ LEON
Title or Position: MANAGING MEMBER
Credential:
Phone: 702-515-9926