# EBEN-EZER GROUP HOME

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- **Entity:** Organization
- **Status:** Active
- **Other names:** none
- **Organization subpart:** No

## Provider details

- **NPI number:** 1588956320
- **Authorized official:** MS. EVELINE CHARLES NURSING ASSISTANCE (ADMINISTRATOR/OWNER)
- **Authorized official phone:** (772) 240-6636

## Contact information

- **Practice address:** 1688 SW BURLINGTON ST, PORT ST LUCIE, FL 34984-3559
- **Practice address phone:** (772) 240-6636
- **Practice address fax:** (772) 249-7004
- **Mailing address:** 1688 SW BURLINGTON ST, PORT ST LUCIE, FL 34984-3559
- **Mailing address phone:** (772) 240-6636
- **Mailing address fax:** (772) 249-7004

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 385HR2060X | Child Intellectual and/or Developmental Disabilities Respite Care | 151427 | FL | Yes |

## Other

- **Enumeration date:** 05/12/2011
- **Last updated:** 05/12/2011