1871533570 NPI number — JANENNE E ELLIS PT

Table of content: JANENNE E ELLIS PT (NPI 1871533570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871533570 NPI number — JANENNE E ELLIS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
JANENNE
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1871533570
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10000 BEACH DR SW UNIT 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALABASH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28467-2856
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-579-2745
Provider Business Mailing Address Fax Number:
910-579-2847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10000 BEACH DR SW UNIT 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALABASH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28467-2856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-579-2745
Provider Business Practice Location Address Fax Number:
910-579-2847
Provider Enumeration Date:
06/08/2006

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:  P2997 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 501889202 . This is a "TRICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1180992 . This is a "FIRSTHEALTH/MAILHANDLERS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1131H . This is a "BLUE CROSS BLUE SHIELD NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 125357800 . This is a "US DEPART OF LABOR" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: E2499 . This is a "MEDCOST PROVIDER #" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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