MEDICARE: MRS. LESLIE LARAE ELLIOTT RD, CDN

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	005133-1	NY

General Provider Information

NPI Number	:	1952653800
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LESLIE LARAE ELLIOTT RD, CDN

Provider Business Mailing Address
First Line	:	3810 SKYLINE DR
Second Line	:
City	:	BLUFF POINT
State	:	NY
Zip	:	14478-9730
Country	:	US
Telephone Number	:	315-521-3017
Fax Number	:

Provider Business Practice Location Address
First Line	:	3810 SKYLINE DR
Second Line	:
City	:	BLUFF POINT
State	:	NY
Zip	:	14478-9730
Country	:	US
Telephone Number	:	315-521-3017
Fax Number	:

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

Provider Enumeration Date	:	10/02/2012
Last Update Date	:	10/02/2012

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