Provider Demographics
NPI:1386329928
Name:ELLERY, BEROMIE L (CEO)
Entity type:Individual
Prefix:
First Name:BEROMIE
Middle Name:L
Last Name:ELLERY
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5411 EDGER DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45239-7739
Mailing Address - Country:US
Mailing Address - Phone:513-714-2380
Mailing Address - Fax:
Practice Address - Street 1:5411 EDGER DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45239-7739
Practice Address - Country:US
Practice Address - Phone:513-714-2380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2024-09-19
Deactivation Date:2023-06-26
Deactivation Code:
Reactivation Date:2024-09-19
Provider Licenses
StateLicense IDTaxonomies
OH4504630376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker