MEDICARE: ELLINGSON EYECARE, INC.

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	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	244542	OTHER	IA	MIDLAND'S CHOICE
2	130740	OTHER	IA	EYEMED
3	25241	OTHER	IA	AVESIS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	45844	OTHER	IA	WELLMARK BLUE CROSS BLUE

General Provider Information

NPI Number	:	1467651372
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELLINGSON EYECARE, INC.

Provider Business Mailing Address
First Line	:	1451 CORAL RIDGE AVE STE 518
Second Line	:
City	:	CORALVILLE
State	:	IA
Zip	:	52241-2805
Country	:	US
Telephone Number	:	319-466-0644
Fax Number	:	319-466-0330

Provider Business Practice Location Address
First Line	:	1451 CORAL RIDGE AVE STE 518
Second Line	:
City	:	CORALVILLE
State	:	IA
Zip	:	52241-2805
Country	:	US
Telephone Number	:	319-466-0644
Fax Number	:	319-466-0330

Authorized Official
Title or Position	:	OWNER
Name	:	LARRY D ELLINGSON
Credential	:	O.D.
Telephone Number	:	319-466-0644

Provider Enumeration Date	:	07/12/2007
Last Update Date	:	07/12/2007

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