Provider Demographics
NPI:1487136206
Name:JABEZ CUSTOMIZED LIVING SERVICES
Entity type:Organization
Organization Name:JABEZ CUSTOMIZED LIVING SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PANDORA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:612-272-8009
Mailing Address - Street 1:1417 BROOKDALE DR
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55444-2129
Mailing Address - Country:US
Mailing Address - Phone:612-272-8009
Mailing Address - Fax:
Practice Address - Street 1:1417 BROOKDALE DR
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55444-2129
Practice Address - Country:US
Practice Address - Phone:612-272-8009
Practice Address - Fax:612-601-8962
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:URBAN HOPE MINISTRIES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-29
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health