Provider Demographics
NPI:1023353919
Name:ELLIS CHIROPRACTIC & LASER CENTER, LLC
Entity type:Organization
Organization Name:ELLIS CHIROPRACTIC & LASER CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELDON
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:913-592-2116
Mailing Address - Street 1:703 N WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:KS
Mailing Address - Zip Code:66083-8745
Mailing Address - Country:US
Mailing Address - Phone:913-592-2116
Mailing Address - Fax:913-592-2117
Practice Address - Street 1:703 N WEBSTER ST
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:KS
Practice Address - Zip Code:66083-8745
Practice Address - Country:US
Practice Address - Phone:913-592-2116
Practice Address - Fax:913-592-2117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO02650016OtherBLUE CROSS BLUE SHIELD OF KANSAS CITY
27203OtherBLUE CROSS BLUE SHIELD OF KANSAS
KS0002823Medicare UPIN