=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790035061
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRINITY PRIMARY CARE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2012
-----------------------------------------------------
Last Update Date | 05/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1259 FM 1463 RD STE 400
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-5480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-321-3955
-----------------------------------------------------
Fax | 832-321-3953
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1259 FM 1463 RD STE 400
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-5480
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-321-3955
-----------------------------------------------------
Fax | 832-321-3953
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. BALAKRISHNA R PRABHAKAR
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 832-321-3955
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | N1075
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | N1075
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------