Provider Demographics
NPI:1104122126
Name:TREVINO, JUAN JESUS (RD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:JESUS
Last Name:TREVINO
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3640 PENCIL STICK DR
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78582-9301
Mailing Address - Country:US
Mailing Address - Phone:956-735-0105
Mailing Address - Fax:956-486-2720
Practice Address - Street 1:3640 PENCIL STICK DR
Practice Address - Street 2:
Practice Address - City:RIO GRANDE CITY
Practice Address - State:TX
Practice Address - Zip Code:78582-9301
Practice Address - Country:US
Practice Address - Phone:956-735-0105
Practice Address - Fax:956-486-2720
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00874957133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered