MEDICARE: MRS. CINDY L ELLIS EEG TECHNICIAN

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	2472E0500X	EEG Technician

General Provider Information

NPI Number	:	1700877008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CINDY L ELLIS EEG TECHNICIAN

Provider Business Mailing Address
First Line	:	100 COLORADO CT
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30240-9523
Country	:	US
Telephone Number	:	706-884-3502
Fax Number	:	706-845-3700

Provider Business Practice Location Address
First Line	:	100 COLORADO CT
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30240-9523
Country	:	US
Telephone Number	:	706-884-3502
Fax Number	:	706-845-3700

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

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	07/08/2007

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