Healthcare Provider Details

I. General information

NPI: 1063059947
Provider Name (Legal Business Name): TRIDENT CORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 W CORDOVA RD
SANTA FE NM
87505-1822
US

IV. Provider business mailing address

524 W CORDOVA RD
SANTA FE NM
87505-1822
US

V. Phone/Fax

Practice location:
  • Phone: 505-216-1152
  • Fax:
Mailing address:
  • Phone: 505-216-1152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number
License Number State

VIII. Authorized Official

Name: APRIL BANCROFT
Title or Position: MANAGER
Credential:
Phone: 505-216-1152