Healthcare Provider Details

I. General information

NPI: 1477939395
Provider Name (Legal Business Name): ELLIS AVERY MORROW RD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 08/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11134 SHELDON BEND DR
RICHMOND TX
77406-7290
US

IV. Provider business mailing address

PO BOX 263607
HOUSTON TX
77207-3607
US

V. Phone/Fax

Practice location:
  • Phone: 281-734-2577
  • Fax:
Mailing address:
  • Phone: 281-734-2577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberDTO5637
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: