Provider Demographics
NPI:1588956320
Name:EBEN-EZER GROUP HOME
Entity type:Organization
Organization Name:EBEN-EZER GROUP HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:EVELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:NURSING ASSISTANCE
Authorized Official - Phone:772-240-6636
Mailing Address - Street 1:1688 SW BURLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-3559
Mailing Address - Country:US
Mailing Address - Phone:772-240-6636
Mailing Address - Fax:772-249-7004
Practice Address - Street 1:1688 SW BURLINGTON ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-3559
Practice Address - Country:US
Practice Address - Phone:772-240-6636
Practice Address - Fax:772-249-7004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL151427385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child