MEDICARE: LARRY D ELLIS SR.

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	171W00000X	Contractor

General Provider Information

NPI Number	:	1376934778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARRY D ELLIS SR.

Provider Business Mailing Address
First Line	:	2215 STEEP PINE TRL
Second Line	:
City	:	FRESNO
State	:	TX
Zip	:	77545-8831
Country	:	US
Telephone Number	:	832-362-1350
Fax Number	:

Provider Business Practice Location Address
First Line	:	2215 STEEP PINE TRL
Second Line	:
City	:	FRESNO
State	:	TX
Zip	:	77545-8831
Country	:	US
Telephone Number	:	832-362-1350
Fax Number	:

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

Provider Enumeration Date	:	02/07/2015
Last Update Date	:	02/07/2015

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