Provider Demographics
NPI:1679731426
Name:TREVOR NEAL DPM
Entity Type:Organization
Organization Name:TREVOR NEAL DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-651-2320
Mailing Address - Street 1:PO BOX 730
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-0730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 S LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-1947
Practice Address - Country:US
Practice Address - Phone:269-651-2320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITN001392332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7066960001Medicare NSC
MI4857550130Medicare PIN