=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558585240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EBG HEALTH CARE II, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 N PRAIRIE AVE
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63107-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-652-6111
-----------------------------------------------------
Fax | 314-652-1575
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1505 E TRAFFICWAY ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65802-3174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-869-5522
-----------------------------------------------------
Fax | 417-831-7729
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MRS. CAROL L GOURLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 417-869-5522
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 031678
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------