1013961424 NPI number — TRILOGY INTEGRATED HEALTH CARE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013961424 NPI number — TRILOGY INTEGRATED HEALTH CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRILOGY INTEGRATED HEALTH CARE
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:
6
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:
1013961424
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 RIVERSTONE VIS
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BLUE RIDGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30513-6648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-632-4400
Provider Business Mailing Address Fax Number:
706-632-4404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 RIVERSTONE VIS
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BLUE RIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30513-6648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-632-4400
Provider Business Practice Location Address Fax Number:
706-632-4404
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TIDMAN
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
706-632-4400

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CSW002589 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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