Provider Demographics
NPI:1689627978
Name:ELLIS, VALDEN J (DC)
Entity Type:Individual
Prefix:MR
First Name:VALDEN
Middle Name:J
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 1:745 W BRIDGE ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-2000
Mailing Address - Country:US
Mailing Address - Phone:208-782-9793
Mailing Address - Fax:
Practice Address - Street 1:745 W BRIDGE ST
Practice Address - Street 2:SUITE F
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-2000
Practice Address - Country:US
Practice Address - Phone:208-782-9793
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID860111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC8604OtherBLUE CROSS
ID1673838Medicare PIN