MEDICARE: MS. VIRGINIA ISABEL ELLIS PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2033819	TX

General Provider Information

NPI Number	:	1023179934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VIRGINIA ISABEL ELLIS PTA

Provider Business Mailing Address
First Line	:	725 W ELLA AVE
Second Line	:
City	:	KINGSVILLE
State	:	TX
Zip	:	78363-3661
Country	:	US
Telephone Number	:	361-593-3322
Fax Number	:	361-593-3234

Provider Business Practice Location Address
First Line	:	1357 N ARMSTRONG
Second Line	:	TEXAS A&M UNIVERSITY AT KINGSVILLE
City	:	KINGSVILLE
State	:	TX
Zip	:	78363
Country	:	US
Telephone Number	:	361-593-3322
Fax Number	:	361-593-3234

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	07/08/2007

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