Provider Demographics
NPI:1770766610
Name:EBENEZER HEALTHCARE SERVICES,
Entity type:Organization
Organization Name:EBENEZER HEALTHCARE SERVICES,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA AGNES
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP,BC
Authorized Official - Phone:405-378-2119
Mailing Address - Street 1:10444 GREENBRIAR PLACE,
Mailing Address - Street 2:SUITE C
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7660
Mailing Address - Country:US
Mailing Address - Phone:405-378-2119
Mailing Address - Fax:405-759-7022
Practice Address - Street 1:10444 GREENBRIAR PLACE
Practice Address - Street 2:SUITE C
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7660
Practice Address - Country:US
Practice Address - Phone:405-378-2119
Practice Address - Fax:405-759-7022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care