Provider Demographics
NPI:1700213675
Name:EBALO CHIROPRACTIC
Entity Type:Organization
Organization Name:EBALO CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:EBALO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-755-0323
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-08
Last Update Date:2013-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-0004875111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL224990Medicare UPIN