Provider Demographics
NPI:1174886220
Name:ELLIS, DANIEL ADAM (LDO)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:ADAM
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N. 1804 WASHINGTON
Mailing Address - Street 2:YE OLDE OPTICAL SHOPPE
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-4757
Mailing Address - Country:US
Mailing Address - Phone:509-326-3459
Mailing Address - Fax:509-326-3459
Practice Address - Street 1:N. 1804 WASHINGTON
Practice Address - Street 2:YE OLDE OPTICAL SHOPPE
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-4757
Practice Address - Country:US
Practice Address - Phone:509-326-3459
Practice Address - Fax:509-326-3459
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO-00000549156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician