MEDICARE: ELLA HEPHZIBAH

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	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1750784724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLA HEPHZIBAH

Provider Business Mailing Address
First Line	:	1905 4TH ST
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-4039
Country	:	US
Telephone Number	:	517-513-3657
Fax Number	:	517-513-3693

Provider Business Practice Location Address
First Line	:	1190 N WEST AVE STE 812
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49202-2047
Country	:	US
Telephone Number	:	517-513-3657
Fax Number	:	517-513-3693

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2014
Last Update Date	:	10/03/2014

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Directions to “ ELLA HEPHZIBAH ” Practice Location

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