Healthcare Provider Details

I. General information

NPI: 1821334673
Provider Name (Legal Business Name): -TRINITY INTEGRATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2012
Last Update Date: 01/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WEST COURT ST TRINITY INTEGRATIVE MEDICINE LLC
JEFFERSONVILLE IN
47130
US

IV. Provider business mailing address

14 REDGATE CT
SILVER SPRING MD
20905-5726
US

V. Phone/Fax

Practice location:
  • Phone: 859-468-5065
  • Fax:
Mailing address:
  • Phone: 301-989-0548
  • Fax: 301-989-1543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number37305
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01046661A
License Number StateIN

VIII. Authorized Official

Name: DR. RAFAEL CRUZ
Title or Position: OWNER
Credential: MD
Phone: 859-468-5065