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General NPI Number Information
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NPI Number | 1558796326
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Entity Type | Organization
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Legal Business Name | EBENEZER MEDICAL OUTREACH INC
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Dates
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Enumeration Date | 09/11/2013
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Last Update Date | 11/06/2013
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Provider Practice Location Address
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Address Line | 1448 10TH AVE
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City | HUNTINGTON
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State | WV
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Zip | 25701-3581
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Country | US
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Telephone | 304-529-0753
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Fax | 304-529-0591
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Provider Business Mailing Address
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Address Line | 1448 10TH AVE
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City | HUNTINGTON
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State | WV
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Zip | 25701-3581
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Country | US
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Telephone | 304-529-0753
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Fax | 304-529-0591
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Authorized Official
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Title or Position | PIC
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Name | GINA FINLEY
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Credential |
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Telephone | 304-529-0753
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0002X
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Taxonomy Name | Clinic Pharmacy
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License Number | CC0559059
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License Number State | WV
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