MEDICARE: EBANKS RESIDENTIAL SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1174285480
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EBANKS RESIDENTIAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	6833 19TH DR S
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33462-4009
Country	:	US
Telephone Number	:	561-459-0578
Fax Number	:	561-323-2609

Provider Business Practice Location Address
First Line	:	6833 19TH DR S
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33462-4009
Country	:	US
Telephone Number	:	561-459-0578
Fax Number	:	561-323-2609

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	LORNA E EBANKS
Credential	:
Telephone Number	:	561-459-0578

Provider Enumeration Date	:	10/13/2021
Last Update Date	:	10/13/2021

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