1568823318 NPI number — KEITH ROMALIS ELLISON MA, ATC, CES

Table of content: KEITH ROMALIS ELLISON MA, ATC, CES (NPI 1568823318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568823318 NPI number — KEITH ROMALIS ELLISON MA, ATC, CES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLISON
Provider First Name:
KEITH
Provider Middle Name:
ROMALIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA, ATC, CES
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568823318
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ONE LMU DRIVE
Provider Second Line Business Mailing Address:
GERSTEN PAVILION - ATHLETIC TRAINING ROOM
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
424-789-4071
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ONE LMU DRIVE
Provider Second Line Business Practice Location Address:
GERSTEN PAVILION - ATHLETIC TRAINING ROOM
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
424-789-4071
Provider Business Practice Location Address Fax Number:
310-338-4401
Provider Enumeration Date:
03/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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