Healthcare Provider Details

I. General information

NPI: 1649517731
Provider Name (Legal Business Name): ZACHARY D EBNER CPED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2013
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5027 GREEN BAY RD STE 124
KENOSHA WI
53144-1771
US

IV. Provider business mailing address

4523 HARDING RD
KENOSHA WI
53142-3154
US

V. Phone/Fax

Practice location:
  • Phone: 262-654-4300
  • Fax: 262-654-4305
Mailing address:
  • Phone: 262-484-7677
  • Fax: 262-654-4305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: