Provider Demographics
NPI:1376667105
Name:ELLIS, CARL EDWARD JR
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:EDWARD
Last Name:ELLIS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CARL
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:31 S GLADE RD
Mailing Address - Street 2:
Mailing Address - City:FORT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-3909
Mailing Address - Country:US
Mailing Address - Phone:706-866-5097
Mailing Address - Fax:
Practice Address - Street 1:700 CITY HALL DR
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-7802
Practice Address - Country:US
Practice Address - Phone:706-861-3387
Practice Address - Fax:706-861-3332
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH009402261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)