Provider Demographics
NPI:1215139068
Name:DAVID SCOTT ELAM
Entity type:Organization
Organization Name:DAVID SCOTT ELAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ELAM
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC
Authorized Official - Phone:805-733-4542
Mailing Address - Street 1:191 BURTON MESA BLVD
Mailing Address - Street 2:#D
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-1400
Mailing Address - Country:US
Mailing Address - Phone:805-733-4542
Mailing Address - Fax:805-733-4392
Practice Address - Street 1:191 BURTON MESA BLVD
Practice Address - Street 2:#D
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-1400
Practice Address - Country:US
Practice Address - Phone:805-733-4542
Practice Address - Fax:805-733-4392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP5420235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05144ZOtherBLUE SHIELD
CA0663623OtherTRIWEST
CA056582Medicare ID - Type Unspecified