Healthcare Provider Details

I. General information

NPI: 1366680217
Provider Name (Legal Business Name): TRINITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 E HOUSTON ST STE 330
TYLER TX
75702-8368
US

IV. Provider business mailing address

PO BOX 846098
DALLAS TX
75284-6098
US

V. Phone/Fax

Practice location:
  • Phone: 903-525-7995
  • Fax: 903-525-7929
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: MARY ANN HARRISON
Title or Position: PROVIDER ENROLLMENT COORDINATOR
Credential: CPC CMC
Phone: 903-510-1113