Provider Demographics
NPI:1053416149
Name:TRIAD MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:TRIAD MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SILVA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:619-469-4421
Mailing Address - Street 1:5346 JACKSON DR STE B
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-6012
Mailing Address - Country:US
Mailing Address - Phone:619-469-4421
Mailing Address - Fax:619-469-4497
Practice Address - Street 1:5346 JACKSON DR STE B
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-6012
Practice Address - Country:US
Practice Address - Phone:619-469-4421
Practice Address - Fax:619-469-4497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45060332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME03294FMedicaid
CA5617000001Medicare NSC