Healthcare Provider Details

I. General information

NPI: 1427093509
Provider Name (Legal Business Name): EBG HEALTH CARE IV, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1486 N RIVERSIDE RD
OZARK MO
65721-7688
US

IV. Provider business mailing address

1505 E TRAFFICWAY ST
SPRINGFIELD MO
65802-3174
US

V. Phone/Fax

Practice location:
  • Phone: 417-581-7126
  • Fax: 417-581-3949
Mailing address:
  • Phone: 417-869-5522
  • Fax: 417-831-7729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031864
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MRS. CAROL L GOURLEY
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 417-869-5522