Provider Demographics
NPI:1043406705
Name:ELLIS CHIROPRACTIC INC
Entity Type:Organization
Organization Name:ELLIS CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VALDEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-782-9793
Mailing Address - Street 1:745 W. BRIDGE ST. SUITE F
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221
Mailing Address - Country:US
Mailing Address - Phone:208-782-9793
Mailing Address - Fax:208-782-1999
Practice Address - Street 1:745 W BRIDGE ST STE F
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-2000
Practice Address - Country:US
Practice Address - Phone:208-782-9793
Practice Address - Fax:208-782-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-17
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID860111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1368895Medicare PIN