Healthcare Provider Details

I. General information

NPI: 1144229782
Provider Name (Legal Business Name): MICHAEL EDWARD ELLIS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 04/01/2011
Certification Date:
Deactivation Date: 03/18/2006
Reactivation Date: 04/05/2006

III. Provider practice location address

1020 N MAIN ST
CROSSVILLE TN
38555-4091
US

IV. Provider business mailing address

1020 N MAIN ST
CROSSVILLE TN
38555-4091
US

V. Phone/Fax

Practice location:
  • Phone: 931-484-3135
  • Fax: 931-484-7108
Mailing address:
  • Phone: 931-484-3135
  • Fax: 931-484-7108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC0436
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: