| Doctor Name: | MR. CARL EDWARD ELLIS |
| NPI Number: | 1376667105 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | RPH009402 |
| Business Practice Address: | 700 City Hall Dr Fort Oglethorpe, GA - 307427802 |
| Business Phone Number: | 7068613387 |
| Business Fax Number: | 7068613332 |
| Mailing Address: | 31 S Glade Rd, FORT OGLETHORPE |
| State: | GA |
| Postal Code: | 307423909 |
| Phone Number: | 7068665097 |
| Fax Number: | |
| NPI Enumeration Date: | 03/19/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QM0801X |
| License Number: | RPH009402 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Mental Health (Including Community Mental Health Center) |
| Taxonomy Definition: | |