MEDICARE: LAURA A ELLIS PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501010803	MI

General Provider Information

NPI Number	:	1043278666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA A ELLIS PT

Provider Business Mailing Address
First Line	:	5654 BELLE RIDGE CT
Second Line	:
City	:	DRYDEN
State	:	MI
Zip	:	48428
Country	:	US
Telephone Number	:	810-796-9102
Fax Number	:

Provider Business Practice Location Address
First Line	:	1769 S CEDAR
Second Line	:
City	:	IMLAY CITY
State	:	MI
Zip	:	48444
Country	:	US
Telephone Number	:	810-724-0421
Fax Number	:	810-721-0423

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	07/08/2007

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Directions to “ LAURA A ELLIS PT” Practice Location

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