Provider Demographics
NPI:1033169750
Name:TRINITY MISSION OF ITALY, LLC
Entity Type:Organization
Organization Name:TRINITY MISSION OF ITALY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOVE1ITAL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-937-7994
Mailing Address - Street 1:220 DAVENPORT
Mailing Address - Street 2:
Mailing Address - City:ITALY
Mailing Address - State:TX
Mailing Address - Zip Code:76651-3592
Mailing Address - Country:US
Mailing Address - Phone:972-483-6369
Mailing Address - Fax:972-483-6114
Practice Address - Street 1:220 DAVENPORT
Practice Address - Street 2:
Practice Address - City:ITALY
Practice Address - State:TX
Practice Address - Zip Code:76651-3592
Practice Address - Country:US
Practice Address - Phone:972-483-6369
Practice Address - Fax:972-483-6114
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COVENANT DOVE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-11
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116239314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001001871Medicaid
TX675103Medicare Oscar/Certification