Healthcare Provider Details

I. General information

NPI: 1548367998
Provider Name (Legal Business Name): CHRISTOPHER RYAN EBBERTS ATC, PES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 ARGOSY PKWY
RIVERSIDE MO
64150-1512
US

IV. Provider business mailing address

10219 N LAWN AVE
KANSAS CITY MO
64156-3005
US

V. Phone/Fax

Practice location:
  • Phone: 816-505-4408
  • Fax: 816-241-0551
Mailing address:
  • Phone: 816-668-2151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2004023137
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: