1356579957 NPI number — REBECCA MCLAIN ELLIS DPT

Table of content: REBECCA MCLAIN ELLIS DPT (NPI 1356579957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356579957 NPI number — REBECCA MCLAIN ELLIS DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
REBECCA
Provider Middle Name:
MCLAIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

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:
1356579957
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
230 CLEARFIELD AVE
Provider Second Line Business Mailing Address:
SUITE 124
Provider Business Mailing Address City Name:
VIRGINIA BEACH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23462-1832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-321-3383
Provider Business Mailing Address Fax Number:
757-321-3332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 CAMELOT DR
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
VIRGINIA BEACH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23454-2440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-321-4284
Provider Business Practice Location Address Fax Number:
757-321-4287
Provider Enumeration Date:
06/23/2009

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:  2305205989 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251X0800X , with the licence number: 2305205989 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 541869072 . This is a "TAX ID" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: C05501 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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