Provider Demographics
NPI:1154642361
Name:ELLIS, CARLY ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:CARLY
Middle Name:ANN
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 TOWNE LAKE PKWY
Mailing Address - Street 2:STE 104
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-5576
Mailing Address - Country:US
Mailing Address - Phone:770-516-7477
Mailing Address - Fax:770-516-7493
Practice Address - Street 1:2360 TOWNE LAKE PKWY
Practice Address - Street 2:STE 104
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5576
Practice Address - Country:US
Practice Address - Phone:770-516-7477
Practice Address - Fax:770-516-7493
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-011692111N00000X
GACHIRO08782111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor