1013156629 NPI number — TRINITY MEDICAL CLINIC, LLC

Table of content: (NPI 1013156629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013156629 NPI number — TRINITY MEDICAL CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRINITY MEDICAL CLINIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1013156629
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
832 MULBERRY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SELMER
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38375-2334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-424-0200
Provider Business Mailing Address Fax Number:
731-434-0203

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
832 MULBERRY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SELMER
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38375-2334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
731-434-0200
Provider Business Practice Location Address Fax Number:
731-434-0203
Provider Enumeration Date:
02/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HUNT
Authorized Official First Name:
RHONDA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
731-434-0200

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APN0000007669 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3341736 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com