=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760262463
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRIDENT PRIMARY CARE & WELLNESS CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2023
-----------------------------------------------------
Last Update Date | 02/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 875 OLD ROSWELL RD BLDG C, SUITE C-200
-----------------------------------------------------
City | ROSWELL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30076-1659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-731-7000
-----------------------------------------------------
Fax | 678-731-7005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6503 GRAND HICKORY DR
-----------------------------------------------------
City | BRASELTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30517-6240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-478-8077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | RODERICK MALONE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-478-8077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------