Provider Demographics
NPI:1619317161
Name:POMEROY, TREVOR JAMES (IDC)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:JAMES
Last Name:POMEROY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3063 MOUNTAIN VIEW DR APT A
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-1039
Mailing Address - Country:US
Mailing Address - Phone:253-353-4947
Mailing Address - Fax:
Practice Address - Street 1:BMC NAF
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243
Practice Address - Country:US
Practice Address - Phone:760-339-2613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8425OtherINDEPENDENT DUTY CORPSMAN