Basic Information
Provider Information
NPI: 1003014168
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ELLIOTT
FirstName: JOHN
MiddleName: M
NamePrefix: DR.
NameSuffix:  
Credential: C.S.F.A./D.O./PH.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3201 MID DALE LN
Address2:  
City: LOUISVILLE
State: KY
PostalCode: 402202615
CountryCode: US
TelephoneNumber: 5025995778
FaxNumber:  
Practice Location
Address1: 2150 S CENTRAL EXPY STE 130
Address2:  
City: MCKINNEY
State: TX
PostalCode: 750704068
CountryCode: US
TelephoneNumber: 9723638200
FaxNumber: 9723638195
Other Information
ProviderEnumerationDate: 07/10/2007
LastUpdateDate: 09/09/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
175L00000XFFF/11/296ZZN Other Service ProvidersHomeopath 
246ZC0007XSA170KYN Technologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherCertified First Assistant
246ZC0007X107788COY Technologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherCertified First Assistant

No ID Information.


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