Provider Demographics
NPI:1063484459
Name:SWAGEL-WOOTTON EYE CENTER, INC
Entity Type:Organization
Organization Name:SWAGEL-WOOTTON EYE CENTER, INC
Other - Org Name:SWAGEL-WOOTTON EYE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-273-7449
Mailing Address - Street 1:PO BOX 200414
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-3941
Mailing Address - Country:US
Mailing Address - Phone:205-241-0017
Mailing Address - Fax:720-524-1121
Practice Address - Street 1:220 S 63RD ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1619
Practice Address - Country:US
Practice Address - Phone:480-641-3937
Practice Address - Fax:480-924-5072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261Q00000X, 261Q00000X
207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWCLBBMedicare PIN
AZCU0240Medicare PIN