Provider Demographics
NPI:1770763302
Name:EBS SPORTS
Entity type:Organization
Organization Name:EBS SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATHLETIC TRAINER / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:EBERLE
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:309-202-2955
Mailing Address - Street 1:1019 W LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5933
Mailing Address - Country:US
Mailing Address - Phone:309-202-2955
Mailing Address - Fax:
Practice Address - Street 1:1019 W LAKE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5933
Practice Address - Country:US
Practice Address - Phone:309-202-2955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty