MEDICARE: COLE G. ELLIS DC

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	111N00000X	Chiropractor	DC29817	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DC18323A	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1578694212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLE G. ELLIS DC

Provider Business Mailing Address
First Line	:	4490 FANUEL ST
Second Line	:	#D
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-8737
Country	:	US
Telephone Number	:	858-274-9116
Fax Number	:	858-274-9161

Provider Business Practice Location Address
First Line	:	4490 FANUEL ST
Second Line	:	#D
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-4292
Country	:	US
Telephone Number	:	858-274-9116
Fax Number	:	858-274-9161

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

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	04/03/2012

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Directions to “ COLE G. ELLIS DC” Practice Location

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