=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366538373
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRINITY MARIA, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2006
-----------------------------------------------------
Last Update Date | 08/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 723 E 9TH ST
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90813-4611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-437-2797
-----------------------------------------------------
Fax | 562-437-8688
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 723 E 9TH ST
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90813-4611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-437-2797
-----------------------------------------------------
Fax | 562-437-8688
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RANDAL D KLEIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-820-9750
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------