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General NPI Number Information
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NPI Number | 1023156130
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Entity Type | Individual
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Provider Name | GLEN STEPHEN ELLIS C.P.O.
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Gender | Male
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 3553 CASTRO VALLEY BLVD SUITE B
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City | CASTRO VALLEY
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State | CA
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Zip | 94546-4400
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Country | US
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Telephone | 510-537-1210
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Fax | 510-537-1082
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Provider Business Mailing Address
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Address Line | 2260 JEFFREY ST
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City | LIVERMORE
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State | CA
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Zip | 94550-6463
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Country | US
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Telephone | 925-606-9295
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Fax | 925-606-7855
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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