Provider Demographics
NPI:1093059917
Name:TELLIGMAN, KEITH ALLEN
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALLEN
Last Name:TELLIGMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5966 COSTELLO AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY GLEN
Mailing Address - State:CA
Mailing Address - Zip Code:91401-4338
Mailing Address - Country:US
Mailing Address - Phone:818-667-4365
Mailing Address - Fax:
Practice Address - Street 1:5966 COSTELLO AVE
Practice Address - Street 2:
Practice Address - City:VALLEY GLEN
Practice Address - State:CA
Practice Address - Zip Code:91401-4338
Practice Address - Country:US
Practice Address - Phone:818-667-4365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9176172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker