Provider Demographics
NPI:1447373394
Name:DR VIVIAN EBERT INC.
Entity type:Organization
Organization Name:DR VIVIAN EBERT INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:EBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-498-2225
Mailing Address - Street 1:10020 COCONUT RD.
Mailing Address - Street 2:#134
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-8136
Mailing Address - Country:US
Mailing Address - Phone:239-498-2225
Mailing Address - Fax:239-498-0347
Practice Address - Street 1:10020 COCONUT RD.
Practice Address - Street 2:#134
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-8136
Practice Address - Country:US
Practice Address - Phone:239-498-2225
Practice Address - Fax:239-498-0347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-07
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0003942111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL380574300Medicaid
88777Medicare PIN
FL380574300Medicaid