Provider Demographics
NPI:1649450388
Name:ELLIS, CHRISTOPHER JOHN (PT)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:JOHN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21000 NE 28TH AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1421
Mailing Address - Country:US
Mailing Address - Phone:716-870-0728
Mailing Address - Fax:
Practice Address - Street 1:21000 NE 28TH AVE
Practice Address - Street 2:STE 104
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1421
Practice Address - Country:US
Practice Address - Phone:716-870-0728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2187225100000X
FLPT24154225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1649450388Medicaid
NV1649450388Medicaid