Provider Demographics
NPI:1194433193
Name:TREVONNE GILLIARD
Entity type:Organization
Organization Name:TREVONNE GILLIARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TREVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-434-2822
Mailing Address - Street 1:PO BOX 656
Mailing Address - Street 2:
Mailing Address - City:SOUTH FALLSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12779-0656
Mailing Address - Country:US
Mailing Address - Phone:845-434-2822
Mailing Address - Fax:845-434-2821
Practice Address - Street 1:5179 MAIN STREET
Practice Address - Street 2:BX 656
Practice Address - City:SOUTH FALLSBURG
Practice Address - State:NY
Practice Address - Zip Code:12779
Practice Address - Country:US
Practice Address - Phone:845-434-2822
Practice Address - Fax:845-434-2821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-08
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03229509Medicaid