Provider Demographics
NPI:1538696364
Name:VOLLENWEIDER, TREVOR
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:VOLLENWEIDER
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 1:140 W LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-2426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 W LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-2426
Practice Address - Country:US
Practice Address - Phone:985-210-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20000241852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer