Provider Demographics
NPI:1952471047
Name:ELLIS, MITCH (DC)
Entity Type:Individual
Prefix:
First Name:MITCH
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 N MERIDIAN
Mailing Address - Street 2:STE A
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-8647
Mailing Address - Country:US
Mailing Address - Phone:253-770-2245
Mailing Address - Fax:253-770-2249
Practice Address - Street 1:217 N MERIDIAN
Practice Address - Street 2:STE A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-8647
Practice Address - Country:US
Practice Address - Phone:253-770-2245
Practice Address - Fax:253-770-2249
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034430111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor