Provider Demographics
NPI:1508133455
Name:TIMOTHY S. ELLEFSON D.C.,P.C.
Entity Type:Organization
Organization Name:TIMOTHY S. ELLEFSON D.C.,P.C.
Other - Org Name:UNION CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ELLEFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:636-583-2675
Mailing Address - Street 1:66 KENNEDY ST
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:MO
Mailing Address - Zip Code:63084-2011
Mailing Address - Country:US
Mailing Address - Phone:636-583-2675
Mailing Address - Fax:636-583-2675
Practice Address - Street 1:66 KENNEDY ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MO
Practice Address - Zip Code:63084-2011
Practice Address - Country:US
Practice Address - Phone:636-583-2675
Practice Address - Fax:636-583-2675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005765111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000031448Medicare PIN