Provider Demographics
NPI:1881661825
Name:ELLIS, JOHN MICHAEL (LAC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MICHAEL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 DIVISION ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-4882
Mailing Address - Country:US
Mailing Address - Phone:415-431-7600
Mailing Address - Fax:415-431-7608
Practice Address - Street 1:290 DIVISION ST
Practice Address - Street 2:SUITE 400
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-4882
Practice Address - Country:US
Practice Address - Phone:415-431-7600
Practice Address - Fax:415-431-7608
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 9557171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11458741OtherCAQH