MEDICARE: MR. DONALD R ELLISON

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	385H00000X	Respite Care
2	310400000X	Assisted Living Facility
3	320800000X	Mental Illness Community Based Residential Treatment Facility
4	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1396054961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DONALD R ELLISON

Provider Business Mailing Address
First Line	:	2618 PIERCE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77003-6038
Country	:	US
Telephone Number	:	832-269-5641
Fax Number	:	832-742-5869

Provider Business Practice Location Address
First Line	:	2618 PIERCE ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77003-6038
Country	:	US
Telephone Number	:	832-269-5641
Fax Number	:	832-742-5869

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

Provider Enumeration Date	:	09/30/2010
Last Update Date	:	12/28/2023

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