Provider Demographics
NPI:1285001842
Name:TREVINO, TREVIS LEE
Entity Type:Individual
Prefix:MR
First Name:TREVIS
Middle Name:LEE
Last Name:TREVINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 FAIRMOUNT ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1555
Mailing Address - Country:US
Mailing Address - Phone:310-625-9373
Mailing Address - Fax:
Practice Address - Street 1:1851 44TH ST SW STE A
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-6440
Practice Address - Country:US
Practice Address - Phone:616-538-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2022-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3019283855133N00000X
CA1849503021133N00000X
CATT375981872081S0010X, 2083S0010X
MIT6158024978762083S0010X, 2081S0010X, 2083S0010X
CA47385510032255A2300X
MI26010020372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer