Provider Demographics
NPI:1568630085
Name:M. SCOTT ELLENDER, OD AND ELIZABETH A ELLENDER, OD, PC
Entity type:Organization
Organization Name:M. SCOTT ELLENDER, OD AND ELIZABETH A ELLENDER, OD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLENDER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:605-348-7401
Mailing Address - Street 1:1601 MT RUSHMORE RD
Mailing Address - Street 2:#5
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-4588
Mailing Address - Country:US
Mailing Address - Phone:605-348-7401
Mailing Address - Fax:605-348-9773
Practice Address - Street 1:1601 MT RUSHMORE RD
Practice Address - Street 2:UNIT #5
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4588
Practice Address - Country:US
Practice Address - Phone:605-348-7401
Practice Address - Fax:605-348-9773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
S40068Medicare PIN