Provider Demographics
NPI:1740300508
Name:TREVN RESIDENTIAL SERVICES, LLC
Entity type:Organization
Organization Name:TREVN RESIDENTIAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-273-0301
Mailing Address - Street 1:1660 NW PROFESSIONAL PLZ
Mailing Address - Street 2:SUITE J
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-3854
Mailing Address - Country:US
Mailing Address - Phone:614-273-0301
Mailing Address - Fax:614-273-0801
Practice Address - Street 1:1660 NW PROFESSIONAL PLZ
Practice Address - Street 2:SUITE J
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3854
Practice Address - Country:US
Practice Address - Phone:614-273-0301
Practice Address - Fax:614-273-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2517557171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2372703Medicaid