Healthcare Provider Details

I. General information

NPI: 1851839120
Provider Name (Legal Business Name): TRINITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3593 E GRANDE BLVD
TYLER TX
75707-1400
US

IV. Provider business mailing address

PO BOX 846098
DALLAS TX
75284-6098
US

V. Phone/Fax

Practice location:
  • Phone: 903-839-2585
  • 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: ELIAS D FAJARDO
Title or Position: PROVIDER ENROLLMENT MANAGER
Credential:
Phone: 903-510-1113