Provider Demographics
NPI:1205205259
Name:ELLERBROCK SPINE AND SOFT TISSUE SERVICES LLC
Entity Type:Organization
Organization Name:ELLERBROCK SPINE AND SOFT TISSUE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:P
Authorized Official - Last Name:ELLERBROCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-659-2271
Mailing Address - Street 1:120 N. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:OH
Mailing Address - Zip Code:45817-1250
Mailing Address - Country:US
Mailing Address - Phone:419-358-2222
Mailing Address - Fax:419-358-2223
Practice Address - Street 1:120 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:BLUFFTON
Practice Address - State:OH
Practice Address - Zip Code:45817-1246
Practice Address - Country:US
Practice Address - Phone:419-358-2222
Practice Address - Fax:419-358-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2927261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center