Healthcare Provider Details

I. General information

NPI: 1336684760
Provider Name (Legal Business Name): TREVOR JUSTUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3028 NAVARRE AVE
OREGON OH
43616-3308
US

IV. Provider business mailing address

22644 SCHULTZ RD
DEFIANCE OH
43512-9608
US

V. Phone/Fax

Practice location:
  • Phone: 419-697-6850
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number10643
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: