Provider Demographics
NPI:1972917623
Name:ELLIS, MICK (DC)
Entity Type:Individual
Prefix:DR
First Name:MICK
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 1:15 SULLIVAN DR APT B
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:NY
Mailing Address - Zip Code:14059-9510
Mailing Address - Country:US
Mailing Address - Phone:716-239-7935
Mailing Address - Fax:
Practice Address - Street 1:15 SULLIVAN DR APT B
Practice Address - Street 2:
Practice Address - City:ELMA
Practice Address - State:NY
Practice Address - Zip Code:14059-9510
Practice Address - Country:US
Practice Address - Phone:716-239-7935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX012390-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor