Provider Demographics
NPI:1205001526
Name:ELLIS, BRANDON (LMT)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7085 N CAMBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-4715
Mailing Address - Country:US
Mailing Address - Phone:503-285-6320
Mailing Address - Fax:
Practice Address - Street 1:7085 N CAMBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-4715
Practice Address - Country:US
Practice Address - Phone:503-285-6320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12645174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist