Provider Demographics
NPI:1871183608
Name:TREJO, VICTOR (RDN)
Entity Type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:
Last Name:TREJO
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 W GLADSTONE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1818
Mailing Address - Country:US
Mailing Address - Phone:626-824-5267
Mailing Address - Fax:
Practice Address - Street 1:630 W GLADSTONE ST
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1818
Practice Address - Country:US
Practice Address - Phone:626-824-5267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86116420133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty