Provider Demographics
NPI:1841996121
Name:ELLIS, NICHOLAS (LDO)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LDO
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 2672
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37162-2641
Mailing Address - Country:US
Mailing Address - Phone:931-488-5778
Mailing Address - Fax:
Practice Address - Street 1:875 UNION STREET
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160
Practice Address - Country:US
Practice Address - Phone:931-488-5778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2451156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician