Basic Information
| Provider Information | |||||||||
| NPI: | 1316548480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | JAVON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 W GREENLAWN AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489102889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176572638 | ||||||||
| FaxNumber: | 2487112438 | ||||||||
| Practice Location | |||||||||
| Address1: | 41521 W 11 MILE RD | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693705525 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2020 | ||||||||
| LastUpdateDate: | 03/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 156F00000X | Y | Eye and Vision Services Providers | Technician/Technologist |
No ID Information.