Provider Demographics
NPI:1508471228
Name:MCCORT, TRENTON DAVID
Entity Type:Individual
Prefix:
First Name:TRENTON
Middle Name:DAVID
Last Name:MCCORT
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 1:1133 TOPLIFF CIR NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-2202
Mailing Address - Country:US
Mailing Address - Phone:740-279-5774
Mailing Address - Fax:
Practice Address - Street 1:1501 ROBERT J CONLAN BLVD NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-3502
Practice Address - Country:US
Practice Address - Phone:321-726-8116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH13003111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty