Provider Demographics
NPI:1831733310
Name:ELLUL, KENNETH ROSS (DC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROSS
Last Name:ELLUL
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 1:2236 GENERAL BOOTH BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-4092
Mailing Address - Country:US
Mailing Address - Phone:757-918-7761
Mailing Address - Fax:757-689-3597
Practice Address - Street 1:2236 GENERAL BOOTH BLVD STE 110
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-4092
Practice Address - Country:US
Practice Address - Phone:757-918-7761
Practice Address - Fax:757-689-3597
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104557616111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor