Provider Demographics
NPI:1720274129
Name:ELLIS, DAVID MICHAEL (CPO)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MICHAEL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:CPO
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Other - Credentials:
Mailing Address - Street 1:510 22ND AVE E
Mailing Address - Street 2:SUITE# 801 ADVANCE ORTHOTICS & PROSTHETICS,
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-4653
Mailing Address - Country:US
Mailing Address - Phone:320-762-2210
Mailing Address - Fax:320-762-2753
Practice Address - Street 1:510 22ND AVE E
Practice Address - Street 2:SUITE# 801 ADVANCE ORTHOTICS & PROSTHETICS,
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-4653
Practice Address - Country:US
Practice Address - Phone:320-762-2210
Practice Address - Fax:320-762-2753
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist