Healthcare Provider Details

I. General information

NPI: 1174219091
Provider Name (Legal Business Name): YAX TREJO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7986 DAGGET ST
SAN DIEGO CA
92111-2321
US

IV. Provider business mailing address

7986 DAGGET ST
SAN DIEGO CA
92111-2321
US

V. Phone/Fax

Practice location:
  • Phone: 858-300-0460
  • Fax: 858-300-0461
Mailing address:
  • Phone: 858-300-0460
  • Fax: 858-300-0461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: