Provider Demographics
NPI:1467783761
Name:ELLIOTT PEDORTHIC CARE LLC
Entity Type:Organization
Organization Name:ELLIOTT PEDORTHIC CARE LLC
Other - Org Name:ELLIOTT FOOTWEAR & ORTHOTIC SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:541-726-0751
Mailing Address - Street 1:85084 KENSINGTON DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:OR
Mailing Address - Zip Code:97455-9621
Mailing Address - Country:US
Mailing Address - Phone:541-726-0751
Mailing Address - Fax:
Practice Address - Street 1:85084 KENSINGTON DR
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:OR
Practice Address - Zip Code:97455-9621
Practice Address - Country:US
Practice Address - Phone:541-726-0751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier