Provider Demographics
NPI:1043766348
Name:TRACES TRINITY, LLC
Entity Type:Organization
Organization Name:TRACES TRINITY, LLC
Other - Org Name:TRACES OF TIGER ADULT DAY CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE MB
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLIE
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:PENNINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-746-6571
Mailing Address - Street 1:382 BRIDGE CREEK ROAD
Mailing Address - Street 2:
Mailing Address - City:TIGER
Mailing Address - State:GA
Mailing Address - Zip Code:30576
Mailing Address - Country:US
Mailing Address - Phone:706-782-6208
Mailing Address - Fax:706-782-5019
Practice Address - Street 1:92 BETTYS CREEK RD
Practice Address - Street 2:
Practice Address - City:DILLARD
Practice Address - State:GA
Practice Address - Zip Code:30537-2257
Practice Address - Country:US
Practice Address - Phone:706-746-6571
Practice Address - Fax:706-746-5643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty