Provider Demographics
NPI:1942667753
Name:ELLIS, CHRIS ROBERT (PTA)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:ROBERT
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16849 MALLARD LN
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-1309
Mailing Address - Country:US
Mailing Address - Phone:708-476-0350
Mailing Address - Fax:
Practice Address - Street 1:16849 MALLARD LN
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-1309
Practice Address - Country:US
Practice Address - Phone:708-476-0350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.006451314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL160.006451OtherIL PT LICENSE