Provider Demographics
NPI:1972551067
Name:ELLINGSON, KIM (DC)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:ELLINGSON
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 1:20 PALATINE
Mailing Address - Street 2:APT 119
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-1626
Mailing Address - Country:US
Mailing Address - Phone:760-994-9487
Mailing Address - Fax:951-676-2645
Practice Address - Street 1:20 PALATINE
Practice Address - Street 2:APT 119
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-1626
Practice Address - Country:US
Practice Address - Phone:760-994-9487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28478111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC28478Medicare PIN