Provider Demographics
NPI:1467651372
Name:ELLINGSON EYECARE, INC.
Entity Type:Organization
Organization Name:ELLINGSON EYECARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ELLINGSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:319-466-0644
Mailing Address - Street 1:1451 CORAL RIDGE AVE STE 518
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-2805
Mailing Address - Country:US
Mailing Address - Phone:319-466-0644
Mailing Address - Fax:319-466-0330
Practice Address - Street 1:1451 CORAL RIDGE AVE STE 518
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-2805
Practice Address - Country:US
Practice Address - Phone:319-466-0644
Practice Address - Fax:319-466-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA244542OtherMIDLAND'S CHOICE
IA130740OtherEYEMED
IA25241OtherAVESIS
IA259168Medicaid
IA45844OtherWELLMARK BLUE CROSS BLUE
IA259168Medicaid