Provider Demographics
NPI:1609122480
Name:ELLIS, DAVID (DC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
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:PO BOX 2663
Mailing Address - Street 2:
Mailing Address - City:WINNEMUCCA
Mailing Address - State:NV
Mailing Address - Zip Code:89446-2663
Mailing Address - Country:US
Mailing Address - Phone:406-459-5456
Mailing Address - Fax:
Practice Address - Street 1:3200 TRADERS WAY STE C
Practice Address - Street 2:
Practice Address - City:WINNEMUCCA
Practice Address - State:NV
Practice Address - Zip Code:89445-3683
Practice Address - Country:US
Practice Address - Phone:406-459-5456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB01467111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation