Provider Demographics
NPI:1093466468
Name:HARBERT, ETHAN (DC)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:HARBERT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10A S POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:PANA
Mailing Address - State:IL
Mailing Address - Zip Code:62557-1402
Mailing Address - Country:US
Mailing Address - Phone:217-562-9214
Mailing Address - Fax:217-562-4771
Practice Address - Street 1:10A S POPLAR ST
Practice Address - Street 2:
Practice Address - City:PANA
Practice Address - State:IL
Practice Address - Zip Code:62557-1402
Practice Address - Country:US
Practice Address - Phone:217-562-9214
Practice Address - Fax:217-562-4771
Is Sole Proprietor?:No
Enumeration Date:2022-01-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013835111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor