Provider Demographics
NPI:1235607904
Name:ELLIS, DALTON J
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:J
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6111 S 136TH CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-4111
Mailing Address - Country:US
Mailing Address - Phone:402-980-1970
Mailing Address - Fax:
Practice Address - Street 1:6111 S 136TH CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-4111
Practice Address - Country:US
Practice Address - Phone:402-980-1970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-11
Last Update Date:2018-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer