MEDICARE: JOY ELLENBERGER O.D.

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	1650	SC

General Provider Information

NPI Number	:	1588952881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOY ELLENBERGER O.D.

Provider Business Mailing Address
First Line	:	531 GEORGIA AVE
Second Line	:
City	:	NORTH AUGUSTA
State	:	SC
Zip	:	29841-3701
Country	:	US
Telephone Number	:	803-279-5277
Fax Number	:

Provider Business Practice Location Address
First Line	:	531 GEORGIA AVE
Second Line	:
City	:	NORTH AUGUSTA
State	:	SC
Zip	:	29841-3701
Country	:	US
Telephone Number	:	803-279-5277
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2011
Last Update Date	:	07/20/2011

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