Provider Demographics
NPI:1639243702
Name:EBERT, VIVIAN B (DC)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:B
Last Name:EBERT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10020 COCONUT RD. # 134
Mailing Address - Street 2:THE BROOKS TOWN CENTER
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135
Mailing Address - Country:US
Mailing Address - Phone:239-498-2225
Mailing Address - Fax:239-498-0347
Practice Address - Street 1:10020 COCONUT RD. # 134
Practice Address - Street 2:THE BROOKS TOWN CENTER
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135
Practice Address - Country:US
Practice Address - Phone:239-498-2225
Practice Address - Fax:239-498-0347
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0003942111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL88777Medicare ID - Type Unspecified
T95239Medicare UPIN