Healthcare Provider Details

I. General information

NPI: 1831733310
Provider Name (Legal Business Name): KENNETH ROSS ELLUL D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2236 GENERAL BOOTH BLVD STE 110
VIRGINIA BEACH VA
23456-4092
US

IV. Provider business mailing address

2236 GENERAL BOOTH BLVD STE 110
VIRGINIA BEACH VA
23456-4092
US

V. Phone/Fax

Practice location:
  • Phone: 757-918-7761
  • Fax: 757-689-3597
Mailing address:
  • Phone: 757-918-7761
  • Fax: 757-689-3597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104557616
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: