Provider Demographics
NPI:1407350291
Name:PRESTON, TREVOR NAJEE
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:NAJEE
Last Name:PRESTON
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:PO BOX 3542
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24115-3542
Mailing Address - Country:US
Mailing Address - Phone:276-618-4604
Mailing Address - Fax:276-790-3167
Practice Address - Street 1:916 BROOKDALE ST STE 2
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-3105
Practice Address - Country:US
Practice Address - Phone:276-790-4301
Practice Address - Fax:276-790-3167
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0242569520Medicaid