Provider Demographics
NPI:1760558498
Name:L EDWARD ELLIOTT ET AL PTR ELLIOTT L EDWARD GEN PTR
Entity Type:Organization
Organization Name:L EDWARD ELLIOTT ET AL PTR ELLIOTT L EDWARD GEN PTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF OPTOMETRY
Authorized Official - Prefix:MR
Authorized Official - First Name:L
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-521-1028
Mailing Address - Street 1:3601 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355
Mailing Address - Country:US
Mailing Address - Phone:209-521-1028
Mailing Address - Fax:209-521-7488
Practice Address - Street 1:3601 COFFEE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355
Practice Address - Country:US
Practice Address - Phone:209-521-1028
Practice Address - Fax:209-521-7488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP88152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY49873YMedicare PIN
CA0706260001Medicare NSC