=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881005775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EBENEZER MANAGEMENT SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2014
-----------------------------------------------------
Last Update Date | 05/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 875 WAYZATA BLVD W
-----------------------------------------------------
City | WAYZATA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55391-9418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-473-6655
-----------------------------------------------------
Fax | 952-473-6677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 875 WAYZATA BLVD W
-----------------------------------------------------
City | WAYZATA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55391-9418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-473-6655
-----------------------------------------------------
Fax | 952-473-6677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF HOUSING DEVELOPMENT
-----------------------------------------------------
Name | JILL NOKLEBY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-874-3431
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 28636
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------