Provider Demographics
NPI:1740244656
Name:HALLAK, ELI WILLIAM (ATC)
Entity Type:Individual
Prefix:MR
First Name:ELI
Middle Name:WILLIAM
Last Name:HALLAK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-3700
Mailing Address - Country:US
Mailing Address - Phone:818-790-0325
Mailing Address - Fax:
Practice Address - Street 1:200 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011-3700
Practice Address - Country:US
Practice Address - Phone:818-790-0325
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2255A2300XOtherATHLETIC TRAINER