Healthcare Provider Details

I. General information

NPI: 1942983705
Provider Name (Legal Business Name): TRENTON DEVONTE' GILLIAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 08/09/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TROUT AVE BLDG 159
GROTON CT
06340
US

IV. Provider business mailing address

130 DEWEY AVE
GROTON CT
06340-3343
US

V. Phone/Fax

Practice location:
  • Phone: 860-694-2876
  • Fax:
Mailing address:
  • Phone: 901-849-5952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: