Provider Demographics
NPI:1639425341
Name:ELLINGTON, MACY NEIL
Entity Type:Individual
Prefix:MR
First Name:MACY
Middle Name:NEIL
Last Name:ELLINGTON
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:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1559
Mailing Address - Country:US
Mailing Address - Phone:661-397-8775
Mailing Address - Fax:661-617-2098
Practice Address - Street 1:1400 S UNION AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93307-4179
Practice Address - Country:US
Practice Address - Phone:661-324-4756
Practice Address - Fax:661-617-2099
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA021500116172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARII02700115OtherCCAPP