Provider Demographics
NPI:1457599284
Name:ELLIS, ROGER D (DC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:D
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 1:1508 SCOTTSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37083-2237
Mailing Address - Country:US
Mailing Address - Phone:501-749-6205
Mailing Address - Fax:
Practice Address - Street 1:1508 SCOTTSVILLE RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:TN
Practice Address - Zip Code:37083-2237
Practice Address - Country:US
Practice Address - Phone:501-749-6205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1333111NX0800X
AR1255111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic