Provider Demographics
NPI:1780035774
Name:ELLIS PAIN & PAIN REHABILITATION CENTER
Entity Type:Organization
Organization Name:ELLIS PAIN & PAIN REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARCIAL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:972-875-8600
Mailing Address - Street 1:PO BOX 566455
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31156-6455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:770-504-5162
Practice Address - Street 1:2200 W ENNIS AVE
Practice Address - Street 2:SUITE # A
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-8054
Practice Address - Country:US
Practice Address - Phone:972-875-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9980111NR0400X
TX10136111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty