MEDICARE: TRINITY WILL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	MHL082046	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053495523
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRINITY WILL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 618
Second Line	:
City	:	CLINTON
State	:	NC
Zip	:	28329-0618
Country	:	US
Telephone Number	:	910-590-2971
Fax Number	:	910-596-2971

Provider Business Practice Location Address
First Line	:	140 FAULKNER LN
Second Line	:
City	:	ROSEBORO
State	:	NC
Zip	:	28382-5415
Country	:	US
Telephone Number	:	910-525-5035
Fax Number	:	910-525-5065

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. SHIRLEY MELINDA WILLIAMS
Credential	:
Telephone Number	:	910-525-5035

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	01/02/2008

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Directions to “TRINITY WILL GROUP ” Practice Location

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