Provider Demographics
NPI:1356565030
Name:EBG HEALTH CARE I, INC.
Entity type:Organization
Organization Name:EBG HEALTH CARE I, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOURLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-869-5522
Mailing Address - Street 1:1505 E TRAFFICWAY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-3174
Mailing Address - Country:US
Mailing Address - Phone:417-869-5522
Mailing Address - Fax:417-831-7729
Practice Address - Street 1:2939 MAGAZINE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1245
Practice Address - Country:US
Practice Address - Phone:314-531-0500
Practice Address - Fax:314-531-5455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO033709314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO102710704Medicaid
265817Medicare UPIN