Provider Demographics
NPI:1033390513
Name:ELLINGTON, BRET JAMES (LAC)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:JAMES
Last Name:ELLINGTON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23785 EL TORO RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4762
Mailing Address - Country:US
Mailing Address - Phone:949-235-9494
Mailing Address - Fax:
Practice Address - Street 1:22762 ASPAN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1604
Practice Address - Country:US
Practice Address - Phone:949-235-9494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 11948171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAC11948OtherMEDICARE P-TAN #