Provider Demographics
NPI:1740310432
Name:ELLYSON CHIROPRACTIC CORPORATION
Entity type:Organization
Organization Name:ELLYSON CHIROPRACTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:ELLYSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:530-743-2093
Mailing Address - Street 1:605 E STREET
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901
Mailing Address - Country:US
Mailing Address - Phone:530-743-2093
Mailing Address - Fax:530-743-3301
Practice Address - Street 1:605 E STREET
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901
Practice Address - Country:US
Practice Address - Phone:530-743-2093
Practice Address - Fax:530-743-3301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29423111N00000X
CA29895111N00000X
CA11189111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ26177ZMedicare ID - Type Unspecified