Provider Demographics
NPI:1609026426
Name:ELLIS, KEVIN
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
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 1:4702 W COMMERCIAL DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-7068
Mailing Address - Country:US
Mailing Address - Phone:501-812-5545
Mailing Address - Fax:501-812-5546
Practice Address - Street 1:4702 W COMMERCIAL DR
Practice Address - Street 2:SUITE C
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-7068
Practice Address - Country:US
Practice Address - Phone:501-812-5545
Practice Address - Fax:501-812-5546
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-29
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator