Provider Demographics
NPI:1043362247
Name:ELLIS, JOSHUA CHARLES (ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:CHARLES
Last Name:ELLIS
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 CITY SPRINGS RD
Mailing Address - Street 2:APT 12
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-0155
Mailing Address - Country:US
Mailing Address - Phone:605-737-0464
Mailing Address - Fax:
Practice Address - Street 1:321 KANSAS CITY ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2820
Practice Address - Country:US
Practice Address - Phone:605-394-4860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0107174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist