MEDICARE: TRIFECTA WELLNESS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1932804424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIFECTA WELLNESS, LLC

Provider Business Mailing Address
First Line	:	6841 FOREST HILL AVE UNIT 174
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-1603
Country	:	US
Telephone Number	:	804-621-1131
Fax Number	:

Provider Business Practice Location Address
First Line	:	6841 FOREST HILL AVE UNIT 174
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23225-1603
Country	:	US
Telephone Number	:	804-621-1131
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. AISHA JONES
Credential	:
Telephone Number	:	646-270-5907

Provider Enumeration Date	:	04/03/2023
Last Update Date	:	04/03/2023

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