=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750650131
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAM EBERT OD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2011
-----------------------------------------------------
Last Update Date | 06/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1871 2ND ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97477-2121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-741-0122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1871 2ND ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97477-2121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-741-0122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PAM EBERT
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 541-741-0122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 3484AT
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------