Provider Demographics
NPI:1265700447
Name:ELLIS HOME OXYGEN & MEDICAL EQUIPMENT
Entity type:Organization
Organization Name:ELLIS HOME OXYGEN & MEDICAL EQUIPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT TO THE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:W
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:RN/WHNP-BC
Authorized Official - Phone:276-619-0060
Mailing Address - Street 1:329A CUMMINGS ST
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-3207
Mailing Address - Country:US
Mailing Address - Phone:276-619-0060
Mailing Address - Fax:276-619-0061
Practice Address - Street 1:329A CUMMINGS ST
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24210-3207
Practice Address - Country:US
Practice Address - Phone:276-619-0060
Practice Address - Fax:276-619-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0206009641332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009135618Medicaid
VA1598895518Medicare NSC