Healthcare Provider Details

I. General information

NPI: 1861784340
Provider Name (Legal Business Name): MANDY LYNN TREVINO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3045 GRANGE HALL RD STE 7
HOLLY MI
48442-1020
US

IV. Provider business mailing address

3495 S CENTER RD
BURTON MI
48519-1455
US

V. Phone/Fax

Practice location:
  • Phone: 248-627-4978
  • Fax: 248-627-4927
Mailing address:
  • Phone: 810-424-2011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301099014
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: