Provider Demographics
NPI:1487392429
Name:EBERT, JOHN CHARLES
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:EBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 BULL ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2506
Mailing Address - Country:US
Mailing Address - Phone:803-250-5107
Mailing Address - Fax:803-708-4041
Practice Address - Street 1:1824 BULL ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2506
Practice Address - Country:US
Practice Address - Phone:803-250-5107
Practice Address - Fax:803-708-4041
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach