Healthcare Provider Details

I. General information

NPI: 1689082968
Provider Name (Legal Business Name): TRIDENT DIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4919 W MELROSE AVE S
TAMPA FL
33629-5419
US

IV. Provider business mailing address

4919 W MELROSE AVE S
TAMPA FL
33629-5419
US

V. Phone/Fax

Practice location:
  • Phone: 727-544-4019
  • Fax:
Mailing address:
  • Phone: 727-544-4019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. MANDEEP TANEJA
Title or Position: MGR
Credential:
Phone: 727-544-4019