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General NPI Number Information
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NPI Number | 1336331917
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Entity Type | Organization
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Legal Business Name | ELLIS SURGICAL PAVILION, LLC
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Dates
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Enumeration Date | 08/16/2007
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Last Update Date | 08/16/2007
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Provider Practice Location Address
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Address Line | 1014 FERRIS AVE STE. 214
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City | WAXAHACHIE
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State | TX
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Zip | 75165-2599
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Country | US
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Telephone | 972-938-1368
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Fax |
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Provider Business Mailing Address
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Address Line | 1014 FERRIS AVE STE. 214
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City | WAXAHACHIE
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State | TX
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Zip | 75165-2599
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. J. D. FAJARDO
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Credential | D.P.M.
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Telephone | 972-938-1368
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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