Individual
CHARLES ELLISON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
750 N FREEDOM BLVD, PROVO, UT 84601-1677
(801) 373-4760
Mailing address
750 N FREEDOM BLVD, PROVO, UT 84601-1677
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
179122236
UT
Other
Enumeration date
06/11/2015
Last updated
06/11/2015
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