Provider Demographics
NPI:1851814024
Name:ELLIS, RAYMOND S (ATC)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:S
Last Name:ELLIS
Suffix:
Gender:M
Credentials:ATC
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 336
Mailing Address - Street 2:
Mailing Address - City:JAMESPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11947-0336
Mailing Address - Country:US
Mailing Address - Phone:631-830-1460
Mailing Address - Fax:
Practice Address - Street 1:74 COMMERCE DR. #3
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11947
Practice Address - Country:US
Practice Address - Phone:631-369-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer