Provider Demographics
NPI:1235208547
Name:ELLENDER, WILLIAM J (DC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:ELLENDER
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 1:7835 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70364-3112
Mailing Address - Country:US
Mailing Address - Phone:985-851-0104
Mailing Address - Fax:985-872-4639
Practice Address - Street 1:7835 PARK AVE
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70364-3112
Practice Address - Country:US
Practice Address - Phone:985-851-0104
Practice Address - Fax:985-872-4639
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA465111NS0005X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111NS0005XChiropractic ProvidersChiropractorSports Physician
Not Answered111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1953318Medicaid
LA1953318Medicaid
LA59-464Medicare ID - Type Unspecified