Healthcare Provider Details

I. General information

NPI: 1730016528
Provider Name (Legal Business Name): MELANIE ELLIOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST
DETROIT MI
48201-1916
US

IV. Provider business mailing address

404 IRVIN ST
PLYMOUTH MI
48170-1111
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005988
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: