MEDICARE: TRINITY SUPPORT SERVICES LLC

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	MHL-041-839	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MHL-041-839	OTHER	NC	STATE LICENSE

General Provider Information

NPI Number	:	1477736007
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRINITY SUPPORT SERVICES LLC

Provider Business Mailing Address
First Line	:	PO BOX 2532
Second Line	:
City	:	BURLINGTON
State	:	NC
Zip	:	27216-2532
Country	:	US
Telephone Number	:	336-513-2204
Fax Number	:	336-513-2208

Provider Business Practice Location Address
First Line	:	1717 GAVIN DRIVE
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27260-5506
Country	:	US
Telephone Number	:	336-889-6905
Fax Number	:	336-889-6905

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	MS. SUZANNE SALAAM SALAAM
Credential	:
Telephone Number	:	336-491-5423

Provider Enumeration Date	:	12/05/2007
Last Update Date	:	09/15/2008

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