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General NPI Number Information
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NPI Number | 1851528236
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Entity Type | Organization
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Legal Business Name | BRIAN E. ELLIOTT, O.D.
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Dates
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Enumeration Date | 06/12/2009
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Last Update Date | 06/12/2009
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Provider Practice Location Address
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Address Line | 6331 JACKSON AVE
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City | RIVERBANK
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State | CA
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Zip | 95367-2733
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Country | US
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Telephone | 209-869-3300
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Fax | 209-869-8809
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Provider Business Mailing Address
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Address Line | 6331 JACKSON AVE
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City | RIVERBANK
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State | CA
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Zip | 95367-2733
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Country | US
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Telephone | 209-869-3300
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Fax | 209-869-8809
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Authorized Official
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Title or Position | OWNER
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Name | MR. BRIAN E ELLIOTT
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Credential | O.D.
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Telephone | 209-869-3300
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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 | 9440T
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License Number State | CA
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