1316238926 NPI number — TRINITY PEDIATRIC CLINIC

Table of content: JENNA METCALFE RBT-19-103325 (NPI 1720649411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316238926 NPI number — TRINITY PEDIATRIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRINITY PEDIATRIC CLINIC
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:
1316238926
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1860 CHADWICK DR
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39204-3463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-376-2857
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1860 CHADWICK DR
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39204-3463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-376-2857
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTSON
Authorized Official First Name:
AUDREY
Authorized Official Middle Name:
U
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
601-376-2857

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00118818 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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