MEDICARE: MINADEO EYE CENTER PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1457334039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINADEO EYE CENTER PLLC

Provider Business Mailing Address
First Line	:	3900 E MEXICO AVE STE 102
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80210-3941
Country	:	US
Telephone Number	:	303-800-2078
Fax Number	:	303-800-2078

Provider Business Practice Location Address
First Line	:	2007 N JEFFERSON AVE
Second Line	:
City	:	MOUNT PLEASANT
State	:	TX
Zip	:	75455-2336
Country	:	US
Telephone Number	:	903-572-6655
Fax Number	:	903-572-0213

Authorized Official
Title or Position	:	CEO
Name	:	CHRISTIAN ELLISTON
Credential	:
Telephone Number	:	720-273-7449

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	08/20/2020

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