=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114280922
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRIDENTCARE HEALTH SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2012
-----------------------------------------------------
Last Update Date | 06/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 ABERNATHY RD NE BUILDING 600, SUITE 1700
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-5662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-514-7322
-----------------------------------------------------
Fax | 678-528-5076
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 ABERNATHY RD NE BUILDING 600, SUITE 1700
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-5662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-514-7322
-----------------------------------------------------
Fax | 678-528-5076
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF ADMINISTRATIVE OFFICER
-----------------------------------------------------
Name | MR. VONSTONE WOLFE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-514-7322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 060-R-1032
-----------------------------------------------------
License Number State |
-----------------------------------------------------