Healthcare Provider Details

I. General information

NPI: 1477326585
Provider Name (Legal Business Name): TRINITY COMMUNITY LIVING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2023
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 GORDON RD
MIDDLETOWN NY
10941-3346
US

IV. Provider business mailing address

25 GORDON RD
MIDDLETOWN NY
10941-3346
US

V. Phone/Fax

Practice location:
  • Phone: 646-400-4562
  • Fax:
Mailing address:
  • Phone: 646-400-4562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: EJOVWOKE RIESA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 646-400-4562