Provider Demographics
NPI:1528120458
Name:EBENEZER HOME OF TENNESSEE, INC.
Entity type:Organization
Organization Name:EBENEZER HOME OF TENNESSEE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:VALDOMAR
Authorized Official - Suffix:
Authorized Official - Credentials:NHA ADMINISTRATOR
Authorized Official - Phone:310-995-2603
Mailing Address - Street 1:500 HICKORY HOLLOW TER
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-2115
Mailing Address - Country:US
Mailing Address - Phone:615-731-7130
Mailing Address - Fax:615-731-0743
Practice Address - Street 1:500 HICKORY HOLLOW TER
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-2115
Practice Address - Country:US
Practice Address - Phone:615-731-7130
Practice Address - Fax:615-731-0743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000051314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0445170Medicaid
TN7440473Medicaid
TN445170Medicare Oscar/Certification
TN7440473Medicaid