Provider Demographics
NPI:1316291974
Name:ELLISON, KENDAL J (DC)
Entity type:Individual
Prefix:DR
First Name:KENDAL
Middle Name:J
Last Name:ELLISON
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 1:200 7TH AVE
Mailing Address - Street 2:SUITE 170
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-4668
Mailing Address - Country:US
Mailing Address - Phone:831-713-6554
Mailing Address - Fax:
Practice Address - Street 1:200 7TH AVE
Practice Address - Street 2:SUITE 170
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-4668
Practice Address - Country:US
Practice Address - Phone:831-713-6554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19441111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor