Provider Demographics
NPI:1578694212
Name:ELLIS, COLE G (DC)
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:G
Last Name:ELLIS
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 1:4490 FANUEL ST
Mailing Address - Street 2:#D
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-8737
Mailing Address - Country:US
Mailing Address - Phone:858-274-9116
Mailing Address - Fax:858-274-9161
Practice Address - Street 1:4490 FANUEL ST
Practice Address - Street 2:#D
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-4292
Practice Address - Country:US
Practice Address - Phone:858-274-9116
Practice Address - Fax:858-274-9161
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29817111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC18323AOtherLICENSE