Provider Demographics
NPI:1154585180
Name:ETHELRED ENTERPRISES, LLC.
Entity type:Organization
Organization Name:ETHELRED ENTERPRISES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:CHEYNE
Authorized Official - Last Name:COBBS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:817-408-7636
Mailing Address - Street 1:614 N NEW RD
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-6035
Mailing Address - Country:US
Mailing Address - Phone:254-776-1338
Mailing Address - Fax:254-751-1312
Practice Address - Street 1:614 N NEW RD # 6035
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-6035
Practice Address - Country:US
Practice Address - Phone:254-770-1338
Practice Address - Fax:254-770-1602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-18
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4923T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTX4923OtherEYE MED
TX181493101Medicaid
TX181493101Medicaid