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General NPI Number Information
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NPI Number | 1992985782
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Entity Type | Organization
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Legal Business Name | CARL RICHARD ELLIS DPM
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Dates
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Enumeration Date | 11/08/2007
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Last Update Date | 09/14/2011
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Provider Practice Location Address
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Address Line | 416 JUNIPER DR
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City | CRESTVIEW
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State | FL
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Zip | 32536-9223
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Country | US
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Telephone | 850-682-1778
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Fax |
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Provider Business Mailing Address
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Address Line | 416 JUNIPER DR
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City | CRESTVIEW
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State | FL
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Zip | 32536-9223
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Country | US
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Telephone | 850-682-1778
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CARL RICHARD ELLIS
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Credential | DPM
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Telephone | 850-682-1778
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number |
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License Number State |
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