Basic Information
| Provider Information | |||||||||
| NPI: | 1659000115 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAZQUEZ | ||||||||
| FirstName: | TREVOR | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 FRANCIS PL STE 115 | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631052465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146441978 | ||||||||
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| Practice Location | |||||||||
| Address1: | 950 FRANCIS PL STE 115 | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631052465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146441978 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2022 | ||||||||
| LastUpdateDate: | 06/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2019030594 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.