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General NPI Number Information
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NPI Number | 1902566748
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Entity Type | Organization
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Legal Business Name | ELLICOTTVILLE MEDICAL
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Dates
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Enumeration Date | 12/21/2021
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Last Update Date | 12/21/2021
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Provider Practice Location Address
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Address Line | 5 PARK SQ
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City | ELLICOTTVILLE
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State | NY
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Zip | 14731-7014
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Country | US
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Telephone | 716-257-4397
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1252
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City | ELLICOTTVILLE
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State | NY
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Zip | 14731-1252
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Country | US
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Telephone | 716-257-4397
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KATELYN JOHNSON-CLARK
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Credential | DO
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Telephone | 941-441-7804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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