Provider Demographics
NPI:1144229782
Name:ELLIS, MICHAEL EDWARD (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-4091
Mailing Address - Country:US
Mailing Address - Phone:931-484-3135
Mailing Address - Fax:931-484-7108
Practice Address - Street 1:1020 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-4091
Practice Address - Country:US
Practice Address - Phone:931-484-3135
Practice Address - Fax:931-484-7108
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2011-04-01
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
TNDC0436111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician