Healthcare Provider Details

I. General information

NPI: 1356724413
Provider Name (Legal Business Name): TRINA HEALTH-WITCHITA N.W., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8414 W 13TH ST N STE 200
WICHITA KS
67212-2979
US

IV. Provider business mailing address

8414 W 13TH ST N STE 200
WICHITA KS
67212-2979
US

V. Phone/Fax

Practice location:
  • Phone: 214-364-0304
  • Fax: 866-713-4186
Mailing address:
  • Phone: 214-364-0304
  • Fax: 866-713-4186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DEANE' WALLACE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 916-571-9041