Healthcare Provider Details

I. General information

NPI: 1124336821
Provider Name (Legal Business Name): BENJAMIN MARK EBERLEIN C.N.A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8712 CLIO ST
HOLLIS NY
11423-1200
US

IV. Provider business mailing address

8712 CLIO ST
HOLLIS NY
11423-1200
US

V. Phone/Fax

Practice location:
  • Phone: 703-863-5325
  • Fax:
Mailing address:
  • Phone: 703-863-5325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number342912450110E
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: