| Doctor Name: | MR. GLEN STEPHEN ELLIS |
| NPI Number: | 1023156130 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | C.P.O. |
| License Number: | |
| Business Practice Address: | 3553 Castro Valley Blvd Suite B Castro Valley, CA - 945464400 |
| Business Phone Number: | 5105371210 |
| Business Fax Number: | 5105371082 |
| Mailing Address: | 2260 Jeffrey St, LIVERMORE |
| State: | CA |
| Postal Code: | 945506463 |
| Phone Number: | 9256069295 |
| Fax Number: | 9256067855 |
| NPI Enumeration Date: | 02/01/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |