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General NPI Number Information
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NPI Number | 1760558498
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Entity Type | Organization
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Legal Business Name | L EDWARD ELLIOTT ET AL PTR ELLIOTT L EDWARD GEN PTR
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Dates
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Enumeration Date | 11/27/2006
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Last Update Date | 02/01/2013
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Provider Practice Location Address
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Address Line | 3601 COFFEE RD
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City | MODESTO
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State | CA
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Zip | 95355
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Country | US
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Telephone | 209-521-1028
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Fax | 209-521-7488
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Provider Business Mailing Address
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Address Line | 3601 COFFEE RD
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City | MODESTO
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State | CA
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Zip | 95355
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Country | US
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Telephone | 209-521-1028
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Fax | 209-521-7488
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Authorized Official
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Title or Position | DOCTOR OF OPTOMETRY
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Name | MR. L EDWARD ELLIOTT
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Credential | OD
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Telephone | 209-521-1028
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | FNP88
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License Number State | CA
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