1063712370 NPI number — OLYMPIA TREJO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063712370 NPI number — OLYMPIA TREJO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TREJO
Provider First Name:
OLYMPIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063712370
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1725 WESTHAVEN CT
Provider Second Line Business Mailing Address:
APT. I
Provider Business Mailing Address City Name:
SANTA CRUZ
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95062-1873
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-763-4700
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 WESTRIDGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATSONVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95076-4168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-763-4700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: FHC70042F . This is a "COUNTY OF SANTA CRUZ MEDI-CAL PROVIDER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC70044F . This is a "COUNTY OF SANTA CRUZ MEDI-CAL PROVIDER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ91892Z . This is a "COUNTY OF SANTA CRUZ MEDICARE GROUP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com