Provider Demographics
NPI:1265966501
Name:DENSMORE, TREVOR J
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:J
Last Name:DENSMORE
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 1:2743 W CONGRESS PKWY
Mailing Address - Street 2:1W
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3485
Mailing Address - Country:US
Mailing Address - Phone:779-791-6921
Mailing Address - Fax:
Practice Address - Street 1:2743 W CONGRESS PKWY
Practice Address - Street 2:1W
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3485
Practice Address - Country:US
Practice Address - Phone:779-791-6921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILD525-8009-0075343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)