Individual
JUSTIN ULLOM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1111 VICTOR ST, SAINT LOUIS, MO 63104-4323
(636) 236-5756
Mailing address
1911 S 11TH ST APT C, SAINT LOUIS, MO 63104-4089
(636) 236-5756
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
2020008148
MO
2255A2300X
Athletic Trainer
—
—
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
02/21/2019
Last updated
04/20/2020
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