Provider Demographics
NPI:1134819444
Name:EBENEZER PALACE CORP
Entity type:Organization
Organization Name:EBENEZER PALACE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ODALIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MACHIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-713-0491
Mailing Address - Street 1:290 W 48TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3952
Mailing Address - Country:US
Mailing Address - Phone:305-713-0491
Mailing Address - Fax:786-803-8455
Practice Address - Street 1:290 W 48TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3952
Practice Address - Country:US
Practice Address - Phone:305-713-0491
Practice Address - Fax:786-803-8455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility