Provider Demographics
NPI:1174101562
Name:ELLIS INTEGRATIVE FAMILY PRACTICE INC
Entity type:Organization
Organization Name:ELLIS INTEGRATIVE FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GRETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:352-457-1936
Mailing Address - Street 1:1865 NIGHTINGALE LN
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4360
Mailing Address - Country:US
Mailing Address - Phone:352-457-1936
Mailing Address - Fax:
Practice Address - Street 1:1865 NIGHTINGALE LN STE B
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4360
Practice Address - Country:US
Practice Address - Phone:352-457-1936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-29
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty