Healthcare Provider Details

I. General information

NPI: 1922358084
Provider Name (Legal Business Name): TRINITY PRIMARY CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 W 103RD ST STE 172
KANSAS CITY MO
64114-4503
US

IV. Provider business mailing address

520 W 103RD ST STE 172
KANSAS CITY MO
64114-4503
US

V. Phone/Fax

Practice location:
  • Phone: 913-961-1478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number155480
License Number StateMO

VIII. Authorized Official

Name: MRS. TIWANA ALLEN
Title or Position: APRN
Credential: MSN
Phone: 913-961-1478