1508005885 NPI number — TRINITY III FAMILY OUTREACH

Table of content: (NPI 1508005885)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508005885 NPI number — TRINITY III FAMILY OUTREACH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRINITY III FAMILY OUTREACH
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:
1508005885
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1501 LITTLE GLOUCESTER RD APT F2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLACKWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08012-3445
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-931-5910
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 SPRUANCE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19901-4051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-931-8910
Provider Business Practice Location Address Fax Number:
804-931-8910
Provider Enumeration Date:
02/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
FOX
Authorized Official First Name:
CARY
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
804-931-8910

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8301206 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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