Organization
EBENEZER REST HOME LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JANE F NAMULONDO (OWNER)
(781) 244-7270
Entity
Organization
Contact information
Practice address
18909 RED OAK LN, TRIANGLE, VA 22172-2122
(812) 447-2707
Mailing address
18909 RED OAK LN, TRIANGLE, VA 22172-2122
(812) 447-2707
Taxonomy
Speciality
Code
Description
License number
State
3104A0630X
Assisted Living Facility (Behavioral Disturbances)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
02272020
ASSISTED LIVING FACILITY
VA
Enumeration date
02/27/2020
Last updated
02/27/2020
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