Provider Demographics
NPI:1457050031
Name:SELVAGE, TREVOR M (RD, LD)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:M
Last Name:SELVAGE
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 W GORE ST FL 2
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1141
Mailing Address - Country:US
Mailing Address - Phone:321-843-7976
Mailing Address - Fax:321-843-6870
Practice Address - Street 1:60 W GORE ST FL
Practice Address - Street 2:2ND FLOOR MP127
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1141
Practice Address - Country:US
Practice Address - Phone:321-843-7976
Practice Address - Fax:321-843-6870
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND10260133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered