Healthcare Provider Details

I. General information

NPI: 1689048357
Provider Name (Legal Business Name): EDUARDO TREVINO RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: EDDY TREVINO RD

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2529 S 1ST ST
AUSTIN TX
78704-5466
US

IV. Provider business mailing address

2529 S 1ST ST
AUSTIN TX
78704-5466
US

V. Phone/Fax

Practice location:
  • Phone: 512-978-9500
  • Fax: 512-978-9558
Mailing address:
  • Phone: 512-978-9500
  • Fax: 512-978-9558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT84164
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86044483
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: