MEDICARE: HALEY TRIVOLI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224900000X	Mastectomy Fitter

General Provider Information

NPI Number	:	1891257499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALEY TRIVOLI

Provider Business Mailing Address
First Line	:	232 N BRAND BLVD
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91203-2610
Country	:	US
Telephone Number	:	818-241-5616
Fax Number	:	818-241-0132

Provider Business Practice Location Address
First Line	:	232 N BRAND BLVD
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91203-2610
Country	:	US
Telephone Number	:	818-241-5616
Fax Number	:	818-241-0132

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2019
Last Update Date	:	06/11/2019

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Directions to “ HALEY TRIVOLI ” Practice Location

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