=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205955937
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVEN S. ELLINGER, OD, PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2007
-----------------------------------------------------
Last Update Date | 09/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1612 E. CENTRE AVE.
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49002-4410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-329-1030
-----------------------------------------------------
Fax | 269-329-0966
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1612 E CENTRE AVE
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49002-4410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-329-1030
-----------------------------------------------------
Fax | 269-329-0966
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | DR. STEVEN S. ELLINGER
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 269-329-1030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | B4444X
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------