Healthcare Provider Details

I. General information

NPI: 1093441685
Provider Name (Legal Business Name): JED RILEY ELLENBURG DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 GROCE RD
LYMAN SC
29365-1631
US

IV. Provider business mailing address

12 GROCE RD
LYMAN SC
29365-1631
US

V. Phone/Fax

Practice location:
  • Phone: 864-439-1345
  • Fax: 864-439-1346
Mailing address:
  • Phone: 864-439-1345
  • Fax: 864-439-1346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4838
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: