Provider Demographics
NPI:1922740158
Name:TRYIAL, DEREK LAMONT
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:LAMONT
Last Name:TRYIAL
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 1:9245 LAGUNA SPRINGS DR STE 213
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7991
Mailing Address - Country:US
Mailing Address - Phone:916-529-2359
Mailing Address - Fax:
Practice Address - Street 1:9245 LAGUNA SPRINGS DR STE 213
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7991
Practice Address - Country:US
Practice Address - Phone:916-529-2359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35960R1343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)