Provider Demographics
NPI:1952492894
Name:ELLIOTT, RICHARD W (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:GALLIANO
Mailing Address - State:LA
Mailing Address - Zip Code:70354
Mailing Address - Country:US
Mailing Address - Phone:985-475-5088
Mailing Address - Fax:
Practice Address - Street 1:18598 W MAIN
Practice Address - Street 2:
Practice Address - City:GALLIANO
Practice Address - State:LA
Practice Address - Zip Code:70354
Practice Address - Country:US
Practice Address - Phone:985-475-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA660111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1957925Medicaid
LA1957925Medicaid