Provider Demographics
NPI:1063686889
Name:ELLYSON, DEAN S (DC)
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:S
Last Name:ELLYSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 E ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-5502
Mailing Address - Country:US
Mailing Address - Phone:530-743-2093
Mailing Address - Fax:
Practice Address - Street 1:605 E ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5502
Practice Address - Country:US
Practice Address - Phone:530-743-2093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11189111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA111890OtherSTATE LISCENCE NUMBER
CADC0111890Medicare PIN