Healthcare Provider Details

I. General information

NPI: 1700394301
Provider Name (Legal Business Name): DANIEL JACOB ELLIOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2515
US

IV. Provider business mailing address

1405 GROSBECK RD
LAPEER MI
48446-3418
US

V. Phone/Fax

Practice location:
  • Phone: 231-591-3780
  • Fax:
Mailing address:
  • Phone: 810-441-1640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: