MEDICARE: MS. VIVIAN BEATRICE ELLIS P.T.

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	1033876	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0069361	OTHER	TX	BCBS BLUE LINK
2	8T0329	OTHER	TX	BCBS PAR PLAN PROVIDER #

General Provider Information

NPI Number	:	1902809049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VIVIAN BEATRICE ELLIS P.T.

Provider Business Mailing Address
First Line	:	305 W MILL ST
Second Line	:
City	:	LIVINGSTON
State	:	TX
Zip	:	77351-3226
Country	:	US
Telephone Number	:	936-327-4084
Fax Number	:	936-327-1201

Provider Business Practice Location Address
First Line	:	305 W MILL ST
Second Line	:
City	:	LIVINGSTON
State	:	TX
Zip	:	77351
Country	:	US
Telephone Number	:	936-327-4084
Fax Number	:	936-327-1201

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	06/04/2018

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