Provider Demographics
NPI:1871756114
Name:GRACE EBENUWA
Entity type:Organization
Organization Name:GRACE EBENUWA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:EBENUWA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:323-293-3983
Mailing Address - Street 1:2521 W SLAUSON AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-3248
Mailing Address - Country:US
Mailing Address - Phone:323-293-3983
Mailing Address - Fax:323-293-3965
Practice Address - Street 1:2521 W SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-3248
Practice Address - Country:US
Practice Address - Phone:323-293-3983
Practice Address - Fax:323-293-3965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49545332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies