Healthcare Provider Details

I. General information

NPI: 1114388303
Provider Name (Legal Business Name): TIMOTHY ELLIS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2016
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 PROVIDENCE RD
WAYNE NE
68787-1212
US

IV. Provider business mailing address

1200 PROVIDENCE RD
WAYNE NE
68787-1212
US

V. Phone/Fax

Practice location:
  • Phone: 402-375-7937
  • Fax: 402-375-7956
Mailing address:
  • Phone: 402-375-7937
  • Fax: 402-375-7956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number54
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: