Healthcare Provider Details

I. General information

NPI: 1811924012
Provider Name (Legal Business Name): JAY T ELLIS PT, DPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 03/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 S WOODRUFF AVE
IDAHO FALLS ID
83404-8310
US

IV. Provider business mailing address

PO BOX 1463
IDAHO FALLS ID
83403-1463
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-8879
  • Fax: 208-523-0436
Mailing address:
  • Phone: 208-523-8879
  • Fax: 208-523-0436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberRPT231
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: