Provider Demographics
NPI:1336331917
Name:ELLIS SURGICAL PAVILION, LLC
Entity Type:Organization
Organization Name:ELLIS SURGICAL PAVILION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:J.
Authorized Official - Middle Name:D
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:972-938-1368
Mailing Address - Street 1:1014 FERRIS AVE
Mailing Address - Street 2:STE. 214
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-2599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1014 FERRIS AVE
Practice Address - Street 2:STE. 214
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-2599
Practice Address - Country:US
Practice Address - Phone:972-938-1368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical