Healthcare Provider Details

I. General information

NPI: 1063490092
Provider Name (Legal Business Name): TREVYN LLOYD DESPAIN RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3908 10TH ST
RIVERSIDE CA
92501-3522
US

IV. Provider business mailing address

1128 ALEXIS LN
REDLANDS CA
92374-1839
US

V. Phone/Fax

Practice location:
  • Phone: 951-274-7744
  • Fax: 951-274-7754
Mailing address:
  • Phone: 909-335-6395
  • Fax: 951-274-7754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number24715
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: