Provider Demographics
NPI:1386778827
Name:ELLIOTT, JOHN GRANVILLE (LAC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:GRANVILLE
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3519 NATHAN DR
Mailing Address - Street 2:UNIT A
Mailing Address - City:ANDERSON
Mailing Address - State:CA
Mailing Address - Zip Code:96007-3031
Mailing Address - Country:US
Mailing Address - Phone:858-752-2302
Mailing Address - Fax:530-243-3029
Practice Address - Street 1:1316 COURT ST
Practice Address - Street 2:#4
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1635
Practice Address - Country:US
Practice Address - Phone:530-243-5230
Practice Address - Fax:530-243-3029
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8009171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist