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General NPI Number Information
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NPI Number | 1225226194
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Entity Type | Organization
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Legal Business Name | THE TRIDENT PACIFIC CORPORATION
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Dates
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Enumeration Date | 10/04/2007
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Last Update Date | 10/04/2007
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Provider Practice Location Address
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Address Line | 8001 YOUREE DR STE 550
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City | SHREVEPORT
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State | LA
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Zip | 71115-2325
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Country | US
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Telephone | 318-212-3740
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5455
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City | SHREVEPORT
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State | LA
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Zip | 71135-5455
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Country | US
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Telephone | 318-212-3740
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Fax | 318-212-3758
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. GLENDA MORENO
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Credential |
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Telephone | 318-212-3740
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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