Individual
DR. WAYNE D ELLENBECKER
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
O.D.
Contact information
Practice address
1250 W IRONWOOD DR, SUITE 201, COEUR D ALENE, ID 83814-2679
(208) 667-2255
(208) 765-5889
Mailing address
2140 W RIVERSTONE DR, STE 101, COEUR D ALENE, ID 83814-4968
(208) 667-2255
(208) 765-5889
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
800
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002689900
—
ID
Enumeration date
09/19/2005
Last updated
09/25/2017
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