Healthcare Provider Details

I. General information

NPI: 1548190127
Provider Name (Legal Business Name): ZACHARY SCOTT ELLIS CMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2026
Last Update Date: 05/23/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 COFFEE RD
MODESTO CA
95355-2360
US

IV. Provider business mailing address

1000 BRIGHTON AVE APT 23
MODESTO CA
95355-4225
US

V. Phone/Fax

Practice location:
  • Phone: 209-450-5296
  • Fax:
Mailing address:
  • Phone: 209-450-5296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number97101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: