Healthcare Provider Details

I. General information

NPI: 1073901971
Provider Name (Legal Business Name): RANDALL W ELLIS RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2014
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 KEEWAYDIN DR
SALEM NH
03079-2839
US

IV. Provider business mailing address

2 KEEWAYDIN DRIVE
SALEM NH
03079
US

V. Phone/Fax

Practice location:
  • Phone: 800-995-2673
  • Fax: 888-979-6551
Mailing address:
  • Phone: 800-995-2673
  • Fax: 888-979-6551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN53627
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: