Healthcare Provider Details

I. General information

NPI: 1053495523
Provider Name (Legal Business Name): TRINITY WILL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 FAULKNER LN
ROSEBORO NC
28382-5415
US

IV. Provider business mailing address

PO BOX 618
CLINTON NC
28329-0618
US

V. Phone/Fax

Practice location:
  • Phone: 910-525-5035
  • Fax: 910-525-5065
Mailing address:
  • Phone: 910-590-2971
  • Fax: 910-596-2971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL082046
License Number StateNC

VIII. Authorized Official

Name: MRS. SHIRLEY MELINDA WILLIAMS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 910-525-5035