Provider Demographics
NPI:1568743433
Name:TRUJILLO, ANDY (LMT, NCTMB)
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:TRUJILLO
Suffix:
Gender:M
Credentials:LMT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 W 56TH ST STE 107
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68847-0508
Mailing Address - Country:US
Mailing Address - Phone:308-234-9613
Mailing Address - Fax:308-234-9614
Practice Address - Street 1:2903 W 24TH ST
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-4925
Practice Address - Country:US
Practice Address - Phone:308-234-9613
Practice Address - Fax:308-234-9614
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1982225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1982OtherSTATE OF NEBRASKA - MASSAGE THERAPY ESTABLISHMENT