Provider Demographics
NPI:1023817103
Name:ELLIS, SAMUEL BROOK
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:BROOK
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-0236
Mailing Address - Country:US
Mailing Address - Phone:517-543-1115
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 236
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-0236
Practice Address - Country:US
Practice Address - Phone:517-543-1115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301401616111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor