Healthcare Provider Details

I. General information

NPI: 1639104169
Provider Name (Legal Business Name): KIRK ELLIOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 05/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 OLIVE ST
ARNAUDVILLE LA
70512-0187
US

IV. Provider business mailing address

PO BOX 187
ARNAUDVILLE LA
70512-0187
US

V. Phone/Fax

Practice location:
  • Phone: 337-754-7254
  • Fax: 337-754-8047
Mailing address:
  • Phone: 337-754-7254
  • Fax: 337-754-8047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number023075
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: