Provider Demographics
NPI:1194831115
Name:ELLIS, JOHN LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LYNN
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 1:3391 COUNTY ROAD 2240
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-8546
Mailing Address - Country:US
Mailing Address - Phone:573-729-2295
Mailing Address - Fax:
Practice Address - Street 1:3391 COUNTY ROAD 2240
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560-8546
Practice Address - Country:US
Practice Address - Phone:573-739-4010
Practice Address - Fax:573-458-9041
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO006814171100000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO430848OtherHEALTHLINK
MO628091OtherACN
MO130695OtherBLUECROSSBLUE SHIELD
MO4400136OtherUHC
MO756098703Medicaid
MO118585OtherGROUP HEALTH PLAN
MO1737609OtherFIRST HEALTH
MOOT14OtherPRIVATE HEALTHCARE SYSTEM