1265404388 NPI number — MR. DOUGLAS A ELLIS PHYSICAL THERAPIST

Table of content: MR. DOUGLAS A ELLIS PHYSICAL THERAPIST (NPI 1265404388)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265404388 NPI number — MR. DOUGLAS A ELLIS PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
DOUGLAS
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265404388
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
790 REMINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOLINGBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60440-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-296-2223
Provider Business Mailing Address Fax Number:
630-759-9510

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3233 W CHARLESTON BLVD
Provider Second Line Business Practice Location Address:
STE 107
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89102-1938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-258-9381
Provider Business Practice Location Address Fax Number:
702-258-9584
Provider Enumeration Date:
02/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  0149 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1265404388 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: DL668Z . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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