Healthcare Provider Details

I. General information

NPI: 1720755895
Provider Name (Legal Business Name): TRINITY COMMUNITY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 01/11/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8451 HIGHWAY 23 STE 1
BELLE CHASSE LA
70037-2594
US

IV. Provider business mailing address

8451 HIGHWAY 23 STE 1
BELLE CHASSE LA
70037-2594
US

V. Phone/Fax

Practice location:
  • Phone: 504-417-3728
  • Fax:
Mailing address:
  • Phone: 504-417-3728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. MARY E MARTINEZ
Title or Position: CONSULTANT
Credential:
Phone: 504-417-3728