Healthcare Provider Details

I. General information

NPI: 1578402939
Provider Name (Legal Business Name): EBENEZER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 NE 218TH AVE
FAIRVIEW OR
97024-8778
US

IV. Provider business mailing address

4055 NE 218TH AVE
FAIRVIEW OR
97024-8778
US

V. Phone/Fax

Practice location:
  • Phone: 240-423-5267
  • Fax:
Mailing address:
  • Phone: 240-423-5267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: BETHEL ESHETU TADESSE
Title or Position: DIRECTOR
Credential: NP
Phone: 240-423-5267