1447466123 NPI number — JON VINCENT EBERLE PT

Table of content: JON VINCENT EBERLE PT (NPI 1447466123)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447466123 NPI number — JON VINCENT EBERLE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EBERLE
Provider First Name:
JON
Provider Middle Name:
VINCENT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447466123
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4737 N OCEAN DRIVE
Provider Second Line Business Mailing Address:
#201
Provider Business Mailing Address City Name:
LAUDERDALE BY THE SEA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33308-2920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-545-4922
Provider Business Mailing Address Fax Number:
954-545-4923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4747 N OCEAN DRIVE
Provider Second Line Business Practice Location Address:
SUITE 261
Provider Business Practice Location Address City Name:
LAUDERDALE BY THE SEA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-2956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-545-4922
Provider Business Practice Location Address Fax Number:
954-545-4923
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 17504 . This is a "LICENSE#" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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