Healthcare Provider Details

I. General information

NPI: 1275814808
Provider Name (Legal Business Name): ELLIS HOUSE OF FITNESS & REHABILITATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7470 OLD ALEXANDRIA FERRY RD
CLINTON MD
20735-1861
US

IV. Provider business mailing address

7470 OLD ALEXANDRIA FERRY RD
CLINTON MD
20735-1861
US

V. Phone/Fax

Practice location:
  • Phone: 301-877-8870
  • Fax: 301-203-0618
Mailing address:
  • Phone: 301-877-8870
  • Fax: 301-203-0618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JOHN ELLIS
Title or Position: PHYSICAL THERAPY ASSISTANT
Credential:
Phone: 301-877-8870