=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649458308
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN E ELLIS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2008
-----------------------------------------------------
Last Update Date | 10/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 619 E CRAWFORD AVE
-----------------------------------------------------
City | CONNELLSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15425-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-628-1370
-----------------------------------------------------
Fax | 724-628-7314
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 619 E CRAWFORD AVE
-----------------------------------------------------
City | CONNELLSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15425-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-628-1370
-----------------------------------------------------
Fax | 724-628-7314
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOHN E. ELLIS
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 724-628-1370
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | OEG001091
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------