Provider Demographics
NPI:1639230683
Name:ELLINGTON OPTICIANS
Entity Type:Organization
Organization Name:ELLINGTON OPTICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNEROPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ELLINGTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:804-526-6119
Mailing Address - Street 1:201 TEMPLE AVE
Mailing Address - Street 2:B
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2801
Mailing Address - Country:US
Mailing Address - Phone:804-526-6119
Mailing Address - Fax:804-526-0166
Practice Address - Street 1:201 TEMPLE AVE
Practice Address - Street 2:B
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2801
Practice Address - Country:US
Practice Address - Phone:804-526-6119
Practice Address - Fax:804-526-0166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA585332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
VABCBSOtherBCBS PROVIDER #
VA11663464OtherCAQH PROVIDER ID
VA11663464OtherCAQH PROVIDER ID