Healthcare Provider Details

I. General information

NPI: 1558585240
Provider Name (Legal Business Name): EBG HEALTH CARE II, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N PRAIRIE AVE
SAINT LOUIS MO
63107-2302
US

IV. Provider business mailing address

1505 E TRAFFICWAY ST
SPRINGFIELD MO
65802-3174
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-6111
  • Fax: 314-652-1575
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 Number031678
License Number StateMO

VIII. Authorized Official

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