1255569505 NPI number — MRS. ELLA LUCILLE CARROLL HEARING AID DISPENSE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255569505 NPI number — MRS. ELLA LUCILLE CARROLL HEARING AID DISPENSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARROLL
Provider First Name:
ELLA
Provider Middle Name:
LUCILLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
HEARING AID DISPENSE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255569505
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4425 JEFFERSON AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71854
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-773-6270
Provider Business Mailing Address Fax Number:
870-773-6270

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4425 JEFFERSON AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71854
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-773-6270
Provider Business Practice Location Address Fax Number:
870-773-6270
Provider Enumeration Date:
06/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 332S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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