1194433193 NPI number — TREVONNE GILLIARD

Table of content: (NPI 1194433193)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194433193 NPI number — TREVONNE GILLIARD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TREVONNE GILLIARD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1194433193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 656
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH FALLSBURG
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12779-0656
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-434-2822
Provider Business Mailing Address Fax Number:
845-434-2821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5179 MAIN STREET
Provider Second Line Business Practice Location Address:
BX 656
Provider Business Practice Location Address City Name:
SOUTH FALLSBURG
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-434-2822
Provider Business Practice Location Address Fax Number:
845-434-2821
Provider Enumeration Date:
11/08/2022

Additional Information

Authorized Official

Authorized Official Last Name:
GILLIARD
Authorized Official First Name:
TREVONNE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
845-434-2822

Provider Taxonomy Codes

  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 344600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03229509 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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