Provider Demographics
NPI:1679787014
Name:TRUJILLO, TODD (PT)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:TRUJILLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 N LAKE BLVD
Mailing Address - Street 2:BOX 5591
Mailing Address - City:TAHOE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:96145-5591
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 N LAKE BLVD
Practice Address - Street 2:BOX 5591
Practice Address - City:TAHOE CITY
Practice Address - State:CA
Practice Address - Zip Code:96145-5591
Practice Address - Country:US
Practice Address - Phone:707-494-6774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26413225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVFN041ZOtherMEDICARE ID