Provider Demographics
NPI:1912203811
Name:ELLEE CARLSON L.AC. LLC
Entity Type:Organization
Organization Name:ELLEE CARLSON L.AC. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER/ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:ELISABETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:L AC
Authorized Official - Phone:773-386-5843
Mailing Address - Street 1:4914 W BALMORAL AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6015 N CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-4301
Practice Address - Country:US
Practice Address - Phone:773-545-9379
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-10
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000965171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty