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General NPI Number Information
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NPI Number | 1891766952
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Entity Type | Organization
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Legal Business Name | ROBERT L ELWELLJR OD PC
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Dates
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Enumeration Date | 01/27/2006
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Last Update Date | 11/01/2007
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Provider Practice Location Address
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Address Line | 2256 NORTHLAKE PKWY #205
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City | TUCKER
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State | GA
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Zip | 30084-4004
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Country | US
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Telephone | 770-934-0337
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Fax | 770-939-5023
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Provider Business Mailing Address
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Address Line | 2256 NORTHLAKE PKWY #205
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City | TUCKER
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State | GA
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Zip | 30084-4034
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Country | US
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Telephone | 770-934-0337
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Fax | 770-939-5023
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ROBERT L ELWELL JR.
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Credential | OD
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Telephone | 770-934-0337
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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 | OPT000809
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License Number State | GA
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