Healthcare Provider Details

I. General information

NPI: 1255086583
Provider Name (Legal Business Name): TRIFECTA HEALTHCARE SERVICES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5911 MONTICELLO DR
MONTGOMERY AL
36117-1940
US

IV. Provider business mailing address

5911 MONTICELLO DR
MONTGOMERY AL
36117-1940
US

V. Phone/Fax

Practice location:
  • Phone: 334-676-2797
  • Fax: 334-323-7148
Mailing address:
  • Phone: 443-902-8816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JASMINE GRAHAM
Title or Position: OFFICE MANAGER
Credential:
Phone: 334-676-2797