Healthcare Provider Details

I. General information

NPI: 1336331917
Provider Name (Legal Business Name): ELLIS SURGICAL PAVILION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 FERRIS AVE STE. 214
WAXAHACHIE TX
75165-2599
US

IV. Provider business mailing address

1014 FERRIS AVE STE. 214
WAXAHACHIE TX
75165-2599
US

V. Phone/Fax

Practice location:
  • Phone: 972-938-1368
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. J. D. FAJARDO
Title or Position: CEO
Credential: D.P.M.
Phone: 972-938-1368