Provider Demographics
NPI:1679798714
Name:TRINITY CLINIC
Entity type:Organization
Organization Name:TRINITY CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:CPC CMC
Authorized Official - Phone:903-510-1113
Mailing Address - Street 1:PO BOX 5500
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75712-5500
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:3200 TROUP HWY
Practice Address - Street 2:STE 110
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8359
Practice Address - Country:US
Practice Address - Phone:903-510-1125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRINITY CLNIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-16
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH0CL831301OtherBCBS OF TEXAS
TX025522601Medicaid
TX025522601Medicaid
TXCL8313Medicare Oscar/Certification
TX690009077Medicare PIN