Healthcare Provider Details

I. General information

NPI: 1972919009
Provider Name (Legal Business Name): EDDIE ELLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8808 W MILL RD APT 1
MILWAUKEE WI
53225-1853
US

IV. Provider business mailing address

8808 W MILL RD APT 1
MILWAUKEE WI
53225-1853
US

V. Phone/Fax

Practice location:
  • Phone: 414-610-4318
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: