Healthcare Provider Details

I. General information

NPI: 1467019414
Provider Name (Legal Business Name): TERRENCE ELLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2019
Last Update Date: 05/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 FAIRVIEW BLVD
WYOMING MN
55092-8013
US

IV. Provider business mailing address

4770 CENTERVILLE RD APT 320
SAINT PAUL MN
55127-2312
US

V. Phone/Fax

Practice location:
  • Phone: 651-982-7843
  • Fax:
Mailing address:
  • Phone: 320-429-0547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: