=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104085463
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVEN D ELLIOTT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2008
-----------------------------------------------------
Last Update Date | 10/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5315 N BROADWAY ST
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37918-3261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-689-3333
-----------------------------------------------------
Fax | 865-689-3317
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5315 N BROADWAY ST
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37918-3261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-689-3333
-----------------------------------------------------
Fax | 865-689-3317
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMESTRIST/OWNER
-----------------------------------------------------
Name | DR. STEVEN D. ELLIOTT
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 865-689-3333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2347
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------