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General NPI Number Information
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NPI Number | 1154953008
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Entity Type | Individual
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Provider Name | DEMETRIC GAZZARA ELLIS
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Gender | Male
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Dates
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Enumeration Date | 02/09/2020
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Last Update Date | 02/09/2020
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Provider Practice Location Address
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Address Line | 1600 LANSDOWNE DR APT 215
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City | JACKSONVILLE
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State | FL
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Zip | 32211-5151
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Country | US
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Telephone | 904-444-0180
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Fax |
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Provider Business Mailing Address
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Address Line | 1600 LANSDOWNE DR APT 215
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City | JACKSONVILLE
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State | FL
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Zip | 32211-5151
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Country | US
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Telephone | 904-444-0180
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Fax |
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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 | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | 30402
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License Number State | FL
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