Healthcare Provider Details

I. General information

NPI: 1932751716
Provider Name (Legal Business Name): TREVOR LEONARD HUNTLEY LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 05/03/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 S DE ANZA BLVD # A109
SAN JOSE CA
95129-3500
US

IV. Provider business mailing address

568 MENKER AVE APT D
SAN JOSE CA
95128-2450
US

V. Phone/Fax

Practice location:
  • Phone: 669-300-9752
  • Fax:
Mailing address:
  • Phone: 669-300-9752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number18134
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: