Provider Demographics
NPI:1063057206
Name:ELLINGTON, ELISE MARIE (DC)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:MARIE
Last Name:ELLINGTON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 WILLIAMSBURG BLVD
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5538
Mailing Address - Country:US
Mailing Address - Phone:618-791-7287
Mailing Address - Fax:
Practice Address - Street 1:220 EVERGREEN LANE
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-6203
Practice Address - Country:US
Practice Address - Phone:618-655-0333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038013466111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor