Healthcare Provider Details

I. General information

NPI: 1982104634
Provider Name (Legal Business Name): TREVOR L NELSON DPT, PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2018
Last Update Date: 02/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 CONNABLE AVE
PETOSKEY MI
49770-2212
US

IV. Provider business mailing address

820 ARLINGTON AVE
PETOSKEY MI
49770-2469
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-7486
  • Fax: 231-487-7791
Mailing address:
  • Phone: 231-487-7486
  • Fax: 231-487-7791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5501615958
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: