1710124458 NPI number — TREVOR HEDDING

Table of content: TREVOR HEDDING (NPI 1710124458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710124458 NPI number — TREVOR HEDDING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEDDING
Provider First Name:
TREVOR
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1710124458
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
750 N COMMONS DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60504-7940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-303-5380
Provider Business Mailing Address Fax Number:
630-303-5385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5135 20TH ST STE 107
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32966-2208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-226-5123
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/16/2009

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: 237700000X , with the licence number:  AS4804 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 237700000X , with the licence number: 1251-060 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 110359300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".