Provider Demographics
NPI:1023156130
Name:ELLIS, GLEN STEPHEN (CPO)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:STEPHEN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 JEFFREY ST
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-6463
Mailing Address - Country:US
Mailing Address - Phone:925-606-9295
Mailing Address - Fax:925-606-7855
Practice Address - Street 1:3553 CASTRO VALLEY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4400
Practice Address - Country:US
Practice Address - Phone:510-537-1210
Practice Address - Fax:510-537-1082
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist