Provider Demographics
NPI:1760185193
Name:TREJO, ELIEZER ANGEL
Entity Type:Individual
Prefix:
First Name:ELIEZER
Middle Name:ANGEL
Last Name:TREJO
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 1:15508 VICIE AVE
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:MO
Mailing Address - Zip Code:64012-1419
Mailing Address - Country:US
Mailing Address - Phone:816-649-4484
Mailing Address - Fax:
Practice Address - Street 1:4100 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-5082
Practice Address - Country:US
Practice Address - Phone:816-649-4844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer