1760262463 NPI number — TRIDENT PRIMARY CARE & WELLNESS CLINIC LLC

Table of content: (NPI 1760262463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760262463 NPI number — TRIDENT PRIMARY CARE & WELLNESS CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRIDENT PRIMARY CARE & WELLNESS 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:
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Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760262463
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6503 GRAND HICKORY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRASELTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30517-6240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-478-8077
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
875 OLD ROSWELL RD
Provider Second Line Business Practice Location Address:
BLDG C, SUITE C-200
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30076-1659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-731-7000
Provider Business Practice Location Address Fax Number:
678-731-7005
Provider Enumeration Date:
10/02/2023

Additional Information

Authorized Official

Authorized Official Last Name:
MALONE
Authorized Official First Name:
RODERICK
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
678-478-8077

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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