Healthcare Provider Details

I. General information

NPI: 1457599284
Provider Name (Legal Business Name): ROGER D. ELLIS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2009
Last Update Date: 02/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 SCOTTSVILLE RD
LAFAYETTE TN
37083-2237
US

IV. Provider business mailing address

1508 SCOTTSVILLE RD
LAFAYETTE TN
37083-2237
US

V. Phone/Fax

Practice location:
  • Phone: 501-749-6205
  • Fax:
Mailing address:
  • Phone: 501-749-6205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number1333
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number1255
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: