Healthcare Provider Details

I. General information

NPI: 1669729737
Provider Name (Legal Business Name): DYNAMIC ATHLETICS HEALTH & PERFORMANCE INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9111 FLINT ST
OVERLAND PARK KS
66214-1737
US

IV. Provider business mailing address

9111 FLINT ST
OVERLAND PARK KS
66214-1737
US

V. Phone/Fax

Practice location:
  • Phone: 855-939-6264
  • Fax:
Mailing address:
  • Phone: 855-939-6264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number0105408
License Number StateKS

VIII. Authorized Official

Name: DR. THOMAS ALAN EBERLINE
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 785-760-3178