MEDICARE: CAROL H ELLIOTT RD, LD/N

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	ND 215	FL

General Provider Information

NPI Number	:	1306179189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL H ELLIOTT RD, LD/N

Provider Business Mailing Address
First Line	:	18 LAKE VISTA WAY
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-6785
Country	:	US
Telephone Number	:	386-673-2915
Fax Number	:	368-676-1714

Provider Business Practice Location Address
First Line	:	725 W GRANADA BLVD STE 1
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-9406
Country	:	US
Telephone Number	:	386-673-2915
Fax Number	:	368-676-1714

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2009
Last Update Date	:	09/11/2009

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