Provider Demographics
NPI:1356071070
Name:ELLIOTT, KEVIN PAUL (LDO VCM)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:PAUL
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:LDO VCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:175 HIGHWAY 274
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-6045
Mailing Address - Country:US
Mailing Address - Phone:803-619-7025
Mailing Address - Fax:803-831-5049
Practice Address - Street 1:175 HIGHWAY 274
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-6045
Practice Address - Country:US
Practice Address - Phone:803-619-7025
Practice Address - Fax:803-831-5049
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC464156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician