Provider Demographics
NPI:1306853833
Name:EBALO, THOMAS JOSEPH (DC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOSEPH
Last Name:EBALO
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 1:1608 10TH ST
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-1405
Mailing Address - Country:US
Mailing Address - Phone:309-755-0323
Mailing Address - Fax:309-755-9192
Practice Address - Street 1:1608 10TH ST
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-1405
Practice Address - Country:US
Practice Address - Phone:309-755-0323
Practice Address - Fax:309-755-9192
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN915111N00000X
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38311Medicare UPIN
IL224990Medicare ID - Type UnspecifiedCHIROPRACTIC