Healthcare Provider Details

I. General information

NPI: 1679798714
Provider Name (Legal Business Name): TRINITY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 TROUP HWY STE 110
TYLER TX
75701-8359
US

IV. Provider business mailing address

PO BOX 5500
TYLER TX
75712-5500
US

V. Phone/Fax

Practice location:
  • Phone: 903-510-1125
  • Fax:
Mailing address:
  • Phone: 903-324-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
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