=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235530940
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELLETT MEDICAL SUPPLIES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2014
-----------------------------------------------------
Last Update Date | 09/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2011 RUNNING SPRINGS DR
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339-3116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-359-0576
-----------------------------------------------------
Fax | 281-654-5222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 526 KINGWOOD DR 268
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339-4473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-359-0576
-----------------------------------------------------
Fax | 281-354-5222
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BRETT A ELLETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-501-3310
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 341600000X
-----------------------------------------------------
Taxonomy Name | Ambulance
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------