Healthcare Provider Details

I. General information

NPI: 1942455654
Provider Name (Legal Business Name): TRINITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2008
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 HWY 19 SOUTH
ATHENS TX
75751-8950
US

IV. Provider business mailing address

PO BOX 846098
DALLAS TX
75284-6098
US

V. Phone/Fax

Practice location:
  • Phone: 903-675-1725
  • Fax:
Mailing address:
  • Phone: 903-324-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SYLVIA R SHAVER
Title or Position: PHYSICIAN CLINIC SUPPORT COORDINATO
Credential: CPC
Phone: 903-510-1113