Provider Demographics
NPI:1205931995
Name:ELLENBECKER EYE CLINIC, PLLC
Entity type:Organization
Organization Name:ELLENBECKER EYE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:ELLENBECKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-667-2255
Mailing Address - Street 1:1250 W IRONWOOD DR
Mailing Address - Street 2:SUITE 201
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:SUITE 201
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2681
Practice Address - Country:US
Practice Address - Phone:208-667-2255
Practice Address - Fax:208-765-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0224410001Medicare NSC