Provider Demographics
NPI:1104071778
Name:EBENEZER FAMILY HOME, INC
Entity type:Organization
Organization Name:EBENEZER FAMILY HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ERICH
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPESTANY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-376-6767
Mailing Address - Street 1:6690 W 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6239
Mailing Address - Country:US
Mailing Address - Phone:305-857-9425
Mailing Address - Fax:305-223-2371
Practice Address - Street 1:6690 W 14TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6239
Practice Address - Country:US
Practice Address - Phone:305-857-9425
Practice Address - Fax:305-223-2371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-24
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8519310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000208100Medicaid
FL000494700Medicaid