Provider Demographics
NPI:1104074228
Name:EBENEZER HOME CARE LLC
Entity type:Organization
Organization Name:EBENEZER HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HIBBLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-541-5009
Mailing Address - Street 1:1189 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TUNICIA
Mailing Address - State:MS
Mailing Address - Zip Code:38676
Mailing Address - Country:US
Mailing Address - Phone:662-541-5009
Mailing Address - Fax:662-363-0103
Practice Address - Street 1:1189 MAIN ST
Practice Address - Street 2:
Practice Address - City:TUNICIA
Practice Address - State:MS
Practice Address - Zip Code:38676
Practice Address - Country:US
Practice Address - Phone:662-363-0102
Practice Address - Fax:662-363-0103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07988034Medicaid