Provider Demographics
NPI:1568823318
Name:ELLISON, KEITH ROMALIS (MA, ATC, CES)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ROMALIS
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MA, ATC, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE LMU DRIVE
Mailing Address - Street 2:GERSTEN PAVILION - ATHLETIC TRAINING ROOM
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045
Mailing Address - Country:US
Mailing Address - Phone:424-789-4071
Mailing Address - Fax:
Practice Address - Street 1:ONE LMU DRIVE
Practice Address - Street 2:GERSTEN PAVILION - ATHLETIC TRAINING ROOM
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045
Practice Address - Country:US
Practice Address - Phone:424-789-4071
Practice Address - Fax:310-338-4401
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer