Provider Demographics
NPI:1033398433
Name:ELLIS COUNTY OPTICAL, INC.
Entity Type:Organization
Organization Name:ELLIS COUNTY OPTICAL, INC.
Other - Org Name:CLASSIC OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:DR
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:POLLARD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:682-518-9393
Mailing Address - Street 1:101 YMCA DR
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-5124
Mailing Address - Country:US
Mailing Address - Phone:972-937-9757
Mailing Address - Fax:972-938-2966
Practice Address - Street 1:101 YMCA DR
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-5124
Practice Address - Country:US
Practice Address - Phone:972-937-9757
Practice Address - Fax:972-938-2966
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVID W. REAGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH-1191332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
00936TOtherMEDICARE PTAN
TXB25819Medicare UPIN