Basic Information
| Provider Information | |||||||||
| NPI: | 1992212633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CASE MANAGER | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 790 ROBERTS DR | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716555723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703672461 | ||||||||
| FaxNumber: | 8704606133 | ||||||||
| Practice Location | |||||||||
| Address1: | 1802 HWY 82 WEST | ||||||||
| Address2: | |||||||||
| City: | CROSSETT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703647248 | ||||||||
| FaxNumber: | 8703642249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2018 | ||||||||
| LastUpdateDate: | 01/03/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | AR | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.