Healthcare Provider Details

I. General information

NPI: 1881333474
Provider Name (Legal Business Name): EDWARD GELLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 CENTRAL PARK SQ STE 108
LOS ALAMOS NM
87544-4002
US

IV. Provider business mailing address

PO BOX 1090
LOS ALAMOS NM
87544-1090
US

V. Phone/Fax

Practice location:
  • Phone: 505-927-2892
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: