MEDICARE: TRIDENT BEHAVIORAL HEALTHCARE, INC.

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1922358845
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIDENT BEHAVIORAL HEALTHCARE, INC.

Provider Business Mailing Address
First Line	:	6131 US HIGHWAY 19
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34652-2527
Country	:	US
Telephone Number	:	727-842-6900
Fax Number	:	727-842-6902

Provider Business Practice Location Address
First Line	:	6133 US HIGHWAY 19
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34652-2527
Country	:	US
Telephone Number	:	727-842-6900
Fax Number	:	727-842-6902

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. THEODORE KENNETH FERGUSON II
Credential	:
Telephone Number	:	352-232-0839

Provider Enumeration Date	:	09/18/2012
Last Update Date	:	09/18/2012

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