Provider Demographics
NPI:1679895700
Name:ELLIS, TRACY (DC)
Entity Type:Individual
Prefix:
First Name:TRACY
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 1:10317 GREENBRIAR PKWY
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7648
Mailing Address - Country:US
Mailing Address - Phone:405-378-3400
Mailing Address - Fax:866-323-7959
Practice Address - Street 1:10317 GREENBRIAR PKWY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7648
Practice Address - Country:US
Practice Address - Phone:405-378-3400
Practice Address - Fax:866-323-7959
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3509111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor