Provider Demographics
NPI:1386728038
Name:KATHLEEN S. ELLIS
Entity type:Organization
Organization Name:KATHLEEN S. ELLIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-369-7964
Mailing Address - Street 1:327 STATE ST
Mailing Address - Street 2:PO BOX 98
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-1367
Mailing Address - Country:US
Mailing Address - Phone:304-369-7964
Mailing Address - Fax:304-369-7005
Practice Address - Street 1:327 STATE ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-1367
Practice Address - Country:US
Practice Address - Phone:304-369-7964
Practice Address - Fax:304-369-7005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0147485000Medicaid
WV0147485000Medicaid