Healthcare Provider Details

I. General information

NPI: 1922276435
Provider Name (Legal Business Name): TRINITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 CLINIC DR
TYLER TX
75701-2050
US

IV. Provider business mailing address

PO BOX 846098
DALLAS TX
75284-6098
US

V. Phone/Fax

Practice location:
  • Phone: 903-596-9173
  • Fax: 903-592-1684
Mailing address:
  • Phone: 903-324-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARY ANN HARRISON
Title or Position: PHYSICIAN CLINIC SUPPORT COORDINATO
Credential: CPC CMC
Phone: 903-510-1113