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General NPI Number Information
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NPI Number | 1104122126
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Entity Type | Individual
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Provider Name | JUAN JESUS TREVINO R.D.
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Gender | Male
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Dates
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Enumeration Date | 02/09/2011
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Last Update Date | 02/09/2011
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Provider Practice Location Address
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Address Line | 3640 PENCIL STICK DR
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City | RIO GRANDE CITY
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State | TX
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Zip | 78582-9301
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Country | US
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Telephone | 956-735-0105
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Fax | 956-486-2720
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Provider Business Mailing Address
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Address Line | 3640 PENCIL STICK DR
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City | RIO GRANDE CITY
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State | TX
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Zip | 78582-9301
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Country | US
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Telephone | 956-735-0105
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Fax | 956-486-2720
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 00874957
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License Number State | TX
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