Healthcare Provider Details

I. General information

NPI: 1962023838
Provider Name (Legal Business Name): TREVOR SCOTT CAULKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2020
Last Update Date: 05/02/2020
Certification Date: 05/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 W MAIN ST
VILLE PLATTE LA
70586-4325
US

IV. Provider business mailing address

747 W MAIN ST
VILLE PLATTE LA
70586-4325
US

V. Phone/Fax

Practice location:
  • Phone: 863-677-1402
  • Fax:
Mailing address:
  • Phone: 863-677-1402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number309230
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: