Healthcare Provider Details

I. General information

NPI: 1013845536
Provider Name (Legal Business Name): OCTAVIA TRICE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 SOUTH DR
INDIANA PA
15705-1046
US

IV. Provider business mailing address

744 SOUTH ST
INDIANA PA
15701-2939
US

V. Phone/Fax

Practice location:
  • Phone: 724-357-2100
  • Fax:
Mailing address:
  • Phone: 814-961-4924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: