Provider Demographics
NPI:1063490092
Name:DESPAIN, TREVYN LLOYD (RPT)
Entity Type:Individual
Prefix:MR
First Name:TREVYN
Middle Name:LLOYD
Last Name:DESPAIN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 ALEXIS LN
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-1839
Mailing Address - Country:US
Mailing Address - Phone:909-335-6395
Mailing Address - Fax:951-274-7754
Practice Address - Street 1:3908 10TH ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3522
Practice Address - Country:US
Practice Address - Phone:951-274-7744
Practice Address - Fax:951-274-7754
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24715225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA24715OtherPHYSICAL THERAPY LISENCE
CAZZZ23533ZMedicare ID - Type Unspecified