Provider Demographics
NPI:1851528236
Name:BRIAN E. ELLIOTT, O.D.
Entity Type:Organization
Organization Name:BRIAN E. ELLIOTT, O.D.
Other - Org Name:RIVERBANK OPTOMETRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-869-3300
Mailing Address - Street 1:6331 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-2733
Mailing Address - Country:US
Mailing Address - Phone:209-869-3300
Mailing Address - Fax:209-869-8809
Practice Address - Street 1:6331 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:RIVERBANK
Practice Address - State:CA
Practice Address - Zip Code:95367-2733
Practice Address - Country:US
Practice Address - Phone:209-869-3300
Practice Address - Fax:209-869-8809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-12
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9440T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0723780001Medicare NSC