Provider Demographics
NPI:1538466818
Name:STEVENS, TRENTON
Entity Type:Individual
Prefix:
First Name:TRENTON
Middle Name:
Last Name:STEVENS
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 335
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84339-0335
Mailing Address - Country:US
Mailing Address - Phone:208-351-8329
Mailing Address - Fax:
Practice Address - Street 1:60 N CENTER ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84339-9412
Practice Address - Country:US
Practice Address - Phone:208-351-8329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7975292-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor