Provider Demographics
NPI:1689408213
Name:STACHES, TREVAR
Entity type:Individual
Prefix:
First Name:TREVAR
Middle Name:
Last Name:STACHES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4816 HARLOU DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45432-1620
Mailing Address - Country:US
Mailing Address - Phone:478-919-4145
Mailing Address - Fax:
Practice Address - Street 1:4816 HARLOU DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45432-1620
Practice Address - Country:US
Practice Address - Phone:478-919-4145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-27
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHUT844976172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty