Provider Demographics
NPI:1376883694
Name:ELLIS, SAMMY DAVID (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:SAMMY
Middle Name:DAVID
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8302 NW 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-4833
Mailing Address - Country:US
Mailing Address - Phone:954-240-1927
Mailing Address - Fax:
Practice Address - Street 1:8302 NW 75TH AVE
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-4833
Practice Address - Country:US
Practice Address - Phone:954-240-1927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-23
Last Update Date:2013-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA24715374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide