Provider Demographics
NPI:1609649086
Name:EWING, ELLIS D JR (LMT)
Entity Type:Individual
Prefix:MR
First Name:ELLIS
Middle Name:D
Last Name:EWING
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 W MAUMEE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1836
Mailing Address - Country:US
Mailing Address - Phone:517-759-2704
Mailing Address - Fax:
Practice Address - Street 1:1304 W MAUMEE ST APT 2
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1836
Practice Address - Country:US
Practice Address - Phone:517-759-2704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501014073225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist