Healthcare Provider Details

I. General information

NPI: 1215175591
Provider Name (Legal Business Name): LAWRENCE EUGENE ELLIS LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2009
Last Update Date: 01/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 N.W. 39TH I 44 SERVICE RD SUITE 103
OKLAHOMA CITY OK
73112-8739
US

IV. Provider business mailing address

1308 NE 43RD ST
OKLAHOMA CITY OK
73111-5853
US

V. Phone/Fax

Practice location:
  • Phone: 405-557-1655
  • Fax:
Mailing address:
  • Phone: 405-824-5066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number366
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: