Healthcare Provider Details

I. General information

NPI: 1861708232
Provider Name (Legal Business Name): TRINITY SUPPORT GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 SWEETGUM DR
FORT MILL SC
29715-6927
US

IV. Provider business mailing address

PO BOX 962
FORT MILL SC
29716-0962
US

V. Phone/Fax

Practice location:
  • Phone: 803-207-7674
  • Fax:
Mailing address:
  • Phone: 803-207-7674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. TANYA SHADE
Title or Position: ADMINISTRATOR
Credential:
Phone: 803-207-7674