Provider Demographics
NPI:1700394301
Name:ELLIOTT, DANIEL JACOB
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JACOB
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 GROSBECK RD
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-3418
Mailing Address - Country:US
Mailing Address - Phone:810-441-1640
Mailing Address - Fax:
Practice Address - Street 1:25 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2515
Practice Address - Country:US
Practice Address - Phone:231-591-3780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program