Provider Demographics
NPI:1922455294
Name:TREJO, JUAN
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
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 1:13909 ALAMEDA AVE
Mailing Address - Street 2:
Mailing Address - City:CLINT
Mailing Address - State:TX
Mailing Address - Zip Code:79836-6118
Mailing Address - Country:US
Mailing Address - Phone:915-637-5193
Mailing Address - Fax:
Practice Address - Street 1:13909 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:CLINT
Practice Address - State:TX
Practice Address - Zip Code:79836-6118
Practice Address - Country:US
Practice Address - Phone:915-637-5193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX09111246171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81-2635563OtherEIN