MEDICARE: TRINITY MEDICAL MANAGEMENT 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	302R00000X	Health Maintenance Organization	ME86283	FL

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	:	1558559070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRINITY MEDICAL MANAGEMENT LLC

Provider Business Mailing Address
First Line	:	1702 S DIXIE HWY
Second Line	:	STE 2
City	:	LAKE WORTH
State	:	FL
Zip	:	33460-5886
Country	:	US
Telephone Number	:	561-588-0199
Fax Number	:	561-588-0215

Provider Business Practice Location Address
First Line	:	1702 S DIXIE HWY
Second Line	:	STE 2
City	:	LAKE WORTH
State	:	FL
Zip	:	33460-5886
Country	:	US
Telephone Number	:	561-588-0199
Fax Number	:	561-588-0215

Authorized Official
Title or Position	:	MANAGER
Name	:	EVELYN DELEON
Credential	:
Telephone Number	:	561-588-0199

Provider Enumeration Date	:	10/10/2007
Last Update Date	:	06/21/2008

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