Individual
JAY T ELLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT, DPT, CSCS
Contact information
Practice address
3100 S WOODRUFF AVE, IDAHO FALLS, ID 83404-8310
(208) 523-8879
(208) 523-0436
Mailing address
PO BOX 1463, IDAHO FALLS, ID 83403-1463
(208) 523-8879
(208) 523-0436
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
RPT231
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
316942
BLUE SHIELD
ID
05
—
804274500
—
ID
01
—
T0742
BLUE CROSS OF IDAHO
ID
Enumeration date
06/26/2006
Last updated
03/04/2011
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