Provider Demographics
NPI:1225784028
Name:ELLINGTON, BRUCE A
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:ELLINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6506 RAWDON STREAM LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-6834
Mailing Address - Country:US
Mailing Address - Phone:310-422-2958
Mailing Address - Fax:
Practice Address - Street 1:6506 RAWDON STREAM LN
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-6834
Practice Address - Country:US
Practice Address - Phone:310-422-2958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45552042343800000X, 343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45552042Medicaid