Provider Demographics
NPI:1134167703
Name:ELLENBECKER, CINDY L (OD)
Entity type:Individual
Prefix:DR
First Name:CINDY
Middle Name:L
Last Name:ELLENBECKER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1250 W IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2681
Mailing Address - Country:US
Mailing Address - Phone:208-667-2255
Mailing Address - Fax:208-765-5889
Practice Address - Street 1:1250 W IRONWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2679
Practice Address - Country:US
Practice Address - Phone:208-667-2255
Practice Address - Fax:208-765-5889
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID826152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist