=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215607601
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRYDENT SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2021
-----------------------------------------------------
Last Update Date | 01/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 N EASTERN AVE STE 102
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89101-4544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-333-1054
-----------------------------------------------------
Fax | 702-608-7752
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6935 ALIANTE PKWY STE 104-421
-----------------------------------------------------
City | NORTH LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89084-5818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-333-1054
-----------------------------------------------------
Fax | 702-608-7752
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | CRIAG DUERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-820-6186
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------