Provider Demographics
NPI:1265288104
Name:ELLIOTT, TERESA (LDO)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:DAYUPAY
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LDO
Mailing Address - Street 1:5448 WHITTLESEY BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-7298
Mailing Address - Country:US
Mailing Address - Phone:706-322-8046
Mailing Address - Fax:706-322-5621
Practice Address - Street 1:5448 WHITTLESEY BLVD STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-7298
Practice Address - Country:US
Practice Address - Phone:706-322-8046
Practice Address - Fax:706-322-5621
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2177156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician