Healthcare Provider Details

I. General information

NPI: 1184149551
Provider Name (Legal Business Name): DAVID TREVISAN MSOP, CO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 E MICHIGAN AVE
JACKSON MI
49202-3517
US

IV. Provider business mailing address

1407 E MICHIGAN AVE
JACKSON MI
49202-3517
US

V. Phone/Fax

Practice location:
  • Phone: 517-784-1142
  • Fax:
Mailing address:
  • Phone: 517-784-1142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: